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06/11/2004 14:44 209-83630 PAGE 02 <br /> r r <br /> UNIFIED PROGRAM CONSOLIDATED VORM 'TANKS <br /> UNpER.GROUND STORAGE TANKS — ]FACILITY age per Site) Peggy —of— <br /> ❑ 7.PERMANkNTLYCLOSEDSITE <br /> Cl 3.RENEKYAL PERMIT <br /> TYPE OF ACTION ❑ 1.NF W SITE K-1 <br /> S.CHANGE OF INFORMATION ❑ 8.TANK REMOVED <br /> [34.AMENDED PER.M.tT spoeify change local use only 490 <br /> (Check ono item only) 6.TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION <br /> - 1 <br /> $USINESSNAMEI`-oms�FACiLIT`�KA�IEorU6A- inBo'n' 'ul 3 FACILITY ITV + ', F. <br /> 1474.LOC AT AGF.NCY/DISTRICT' <br /> rot FACILITY OWNER TYPE 5,COUNTY AGENCY* <br /> NEAREST CROSS TRE T V e ❑ 1-CORPORATION <br /> S. COMMERCIAL )M 2.INDIVIDUAL []b-STATE AGENCY* <br /> BUSINESS 1,GAS STATION 3,FARM 3,PARTNERSHIP ❑7.FEDERAL AGENCY* r6x <br /> 2-DISTRIBUTOR ❑4.PROCESSOR❑6. OTHER ao1 <br /> TYPE [� —" *it owner of U57 is a public agency:name of supervisor of division,section or otrtce which <br /> TOTAL NUMBER OF TANKS 15 tr stlafacility on lndiut Reservation or operates the UST(This is the contact person for the tank records) <br /> trustlands? � <br /> REMAINING AT SITE 40 <br /> 404 ❑ Yes o <br /> 11. PROPERTY OWNER INFORMATION 4W <br /> / 407 PRONE <br /> PROPERTY OWNER NAME / / c- t fJ � - r <br /> MAILING OR STREET ADDRESS e-� <br /> 411 Zip ODE m2aril STATE411 <br /> CITY t A- J 0 <br /> 1NDIVSDUAL 4.LOCAL AGENCY/DISTRICT 6.STATE AGENCY <br /> PROPERTY OWNER T 1.CORPORATION ❑7.FEDERAL AGENCY 4D <br /> 0 3 PARTNERSHIP 0'5.COUNTY AGENCY <br /> Ill.TANK OWNER INFORMATION 40 <br /> TANKOWNERNAME " ria PHONE y <br /> �Lt t7 ;Ib <br /> �A P <br /> MAILING OR,STREET ADDRESS / , - / l C t,-e e r <br /> / ( ZIP <br /> CODE 419 <br /> 417 STATE 418 <br /> CITY �- <br /> ��� ` <br /> I.CORPORATION 2,INDIVIDUAL 4.[.OGRE AGENCY/DISTRICT szo <br /> b,STATE AGENCY <br /> TANK OWN5R TYPE ❑7-FEDERAL AGENCY <br /> 0 3.PART1`IERSHIP 5.COUNTY AGENCY i <br /> iV.BOARD OF EQ 421 <br /> UST STORAGE.FEE ACCOUNT NUMBER 421 <br /> Call 916)322-9669 if Ruestions S69C <br /> '),'Y TK 11 44- <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILI'T'Y <br /> ❑ 10.LOCAL GOVT MECHANISM <br /> INDICATE METHOD I.SELF-INSURED ❑4.SURETY BOND [17.STATE FUND � <br /> ❑2,GUARANTEE 3.INSURANCE C b.EXEMPTION REDIT 0 9.STATE F9.STATE UND&CD LETTER Q 99,OTHER, <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> 1.FACILITY O 2. PROPERTY OWNER ❑3.TANK OWNER <br /> 4Z3 <br /> Cheek one boz to indieYte which address should be used for te9al nonfreations and mgilin>i- <br /> L,:pl notwiications gild mailings will be sent to the tank owner unlexs b070 or is checked. <br /> VII.APPLICANT SIGNATUPM <br /> r25 <br /> CCftlftcgdOli-I Certify that the information provided herein is tn<grid acctstate to the best of my DATE¢e 424 PHONErr �/ <br /> SIGNATURE OF APPLICANT �� ( -p 44-3 J <br /> 427 <br /> 426 TITLE OF APPLICANT <br /> NAME OF APPLICANT(print) <br /> 4V <br /> 4z8 1998 UPGRADE CERTIFICATE NUMBi R(Por twat twc only) <br /> STATE Vs FACILITY NUMBER(I'v toca"only) <br /> 8 Fonncrly SWRCB Form�. <br /> UPCF(1199 revised) <br />