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P <br /> UNIFIED PROGRAM CONSOLIDATED FOR !TIANKSERG OUND S i ORAGE TANKS - FACILITY(one page per site) Page <br /> 7.PERMANENTLY CLOSED SITE <br /> TYPE OF ACTION 1.NEW SITE PERMIT ❑3.RENEWAL PERMIT ❑S.CRANGE OF INFORMATION [3 g TANK REMOVED <br /> (Check one item only) E]4.AMENDED PERMIT specify change local use only <br /> ❑6.TEMPORARY SITE CLOSURE <br /> 400 <br /> I. FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Same as FACIlXrY NAME or DBA-Doing Bus s As) 3 FA I'I'1 1D# 1 <br /> 5 ®� 4.LOCAL AGENCY/)ISTRICT* <br /> NEAREST4R ' STREET j 4ot FACILITY <br /> OWNERTYPE <br /> l 1.CORPORATION ❑5.COUNTY AGENCY* <br /> BLTSINESS ❑t.GAS STATION Ej 3.FARM u 5. CONMMIERCLAL [12.INDIVIDUAL ❑6.STATE AGENCY* <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR❑6. OTHER 4103 ❑ 3.PARTNERSHIP ❑ <br /> 7.FEDERAL AGENCY* 402 <br /> TOTAL NUMBER OF TANKS Is facility on Indian Reservation or *If owner of UST is a public agency:name of supervisor of division,section or office which <br /> REMAINING AT SITE trustlands? operates the UST(This is the contact person for the tank records.) <br /> 406 <br /> Oat ❑ Yes ❑ No 405 <br /> IL PROPERTY OWNER INFORMATION / <br /> 4107 PHONE [� 408 <br /> PROPERTY O qER NAMEL` qua V15- <br /> fidf <br /> ' �✓� ! 409 <br /> MAILING OR STREET DRES Q " <br /> OG 4t1 ZIP CODE d1' <br /> 411074. <br /> q &I / <br /> CITY ` <br /> I Kv <br /> PR f3PERTY1OWNER TYPE 1.CORPORATION 2.INDIVIDUALLOCAL AGENC /DISTRICT 6.STATE AGENCY 113 <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> III.TANK OWNER INFORMATION <br /> 41417H­OX�E �� 4j5 <br /> TANK OWNER NAME e <br /> 416 <br /> MAILING OR STREET ADDRESS <br /> 417 1 STATE 413 ZIP CODE 119 <br /> CITY <br /> TANK OWNER TYPE 1.CORPORATION 2.INDIVIDUAL El 4.LOCAL AGENCY/DISTRICT 6.STATE AGENCY 420 <br /> [13.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> ;=` <br /> TY(TK)M 44- <br /> Call(916}322-9669 if stions arise <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> ❑10.LOCAL GOVT MECHANISM <br /> kn THODI❑1.SELF-INSURED [14.SURETY BOND ❑7•STATE FUND <br /> ❑2.GUARANTEE 0 5.LETTER OF CREDIT ❑g.STATE FUND&CFO LETTER ❑ 99.OTHER: 422 <br /> J,3.INSURANCE [16.EXEMPTION ❑9.STATE FUND&CD <br /> VL LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one box to indicate which address should be used for legal notifications and mailing. 423 <br /> Legal notifications and mailings will be sent to the tank owner unless box 1 or 2 is checked. ❑ 1.FACILITY JW2.PROPERTY OWNER ❑3.TANK OWNER <br /> VII.APPLICANT SIGNATURE <br /> Certification- ertify that the information p ed herein is true and accurate to the best of my knowledge.ATE 424 PHONE 1,z <br /> SIGNATURE FAPP ICANT D� <br /> NAME OF APP ICA ( Tint 476 TITLF,,OF ADPL CAjNT <br /> STATE UST FACILITY NUMBER(Forbcal aseoaty) <br /> 423 1998 UPGRADE CERTIFICATE NUMBER'(For beat use only) <br /> IIPCF(1/99 revised) <br /> 8 Formerly SWRCB FoITn A <br />