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UNIFIED PROGRAM CONSOLIDATED FORM 01 TANKS UNDERGROUND S'TORAGE TANKS - FACILITY , (One page per site) Page_of TYPE OF ACTION ❑1.NEW PERMIT ❑3.RENEWAL PERMIT ®.5.CHARGE OF INFORMATION ❑7.PERMANENTLY CLOSED SITE 400. [[ (Check one item only) ❑4.AMENDED PERMIT (Specify change); LJ CW 4)"S . ❑8.TANK REMOVED ❑6.TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION BUSINESS NAME(Same as FACB.TI'Y NAME or DBA-Doing Business As) 3. 1 FACILITY L � ID# 1,�,4 () o � � [I] NEAREST CROSS STREET 401. FACILITY OWNER TYPE El 4.LOCAL AGENCY/DISTRICT* 402• ❑1.CORPORATION ❑5.COUNTY AGENCY* BUSINESS[91.GAS STATION ❑3.FARM [15.COMMERCIAL 403. S(2,INDIVIDUAL ❑6.STATE AGENCY* TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR [16.OTHER [13.PARTNERSHIP ❑7.FEDERAL AGENCY* TOTAL NUMBER OF TANKS 404. Is facility on Indian Reservation 405. *If owner of UST is a public agency:name of supervisor of division,section or 406. REMAINING AT SITE or trust lands? office which operates the UST. (This is the contact person for the tank records.) ❑Yes %No II. PROPERTY OWNER INFORMATION PROPERTY OWNER NAM!, 407• PHONE 408. Zo 01011 MAILING OR STREET ADD SS 409. 0 -7 (o CITY a10. ST TE au. ZIP CODE 412. q co PROPERTY OWNER TYPE El 1.CORPORATION 2.INDIVIDUAL Ll 4.LOCAL AGENCY/DISTRICT 6.STATE AGENCY 411 ❑3.PARTNERSHIP [15.COUNTY AGENCY ❑7.FEDERAL AGENCY I III.TANK OWNER INFORMATION TANK OWNER NAME-, 414. PHONE 415, MAILING OR STREET ADDRESS 416. CITY 417. STATEn 418. ZIP CQPE 419. k P-s-r -tq V 13 404 TANK OWNER TYPE ❑1.CORPORATION K2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 420. ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY TK)HQ 44- 1 1 1 1 1 1 1 Call 916)322-9669 if questions arise 421. V.PETROLEUM UST FINANCIAL RESPONSIBILITY INDICATE METHOD(s) [11.SELF-INSURED ❑4.SURETY BOND ❑7.STATE FUND ❑10.LOCAL GOVT MECHANISM 422 rl 2.GUARANTEE [15.LETTER OF CREDIT � STATE FUND&CFO LETTER [199.OTHER: INSURANCE ❑6.EXEMPTION 13-9.9.STATE FUND&CD VI.LEGAL NOTIFICATION AND MAILING ADDRESS Check one box to indicate which address should be used for legal notifications and mailing. Legal notifications and mailings will be sent to the tank owner unless box 1 or 2 is checked. JAL FACILITY ❑2. PROPERTY OWNER ❑3.TANK OWNER 423• VII.APPLICANT SIGNATURE Certification: I c that the information provided h in is true and accurate to the best of my knowledge. SIGNATURE O PLICANT DATE 424. 1 PHONE 425. Ax I 2q , C? I;L -q I NAME F APPL ANT(print) 426. TITLE EAPPLICANT 427. Imo►i2 ) STATE UST FACILITY NUMBER(Agency use only) 423. 1998 UPGRADE CERTIFICATE NUMBER(Agency use only) 429. (See Data Element 1,above. UPCF Hwfwrc-a(1/99)-1/2 http://www.unidocs.org Rev.02/16/00