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UNIFIED PROGRAM CONSOLIDATED FORM 01 <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (One page per site) Page_of <br /> TYPE OF ACTION ❑1.NEW PERMIT ❑3.RENEWAL PERMIT 5.C GE OF IN^FORMATION [37.PERMANENTLY CLOSED SITE 400• <br /> (Check one item only) [34.AMENDED PERMIT (Specify change)AJC-:Lal Ci W A)E 2 ❑8.TANK REMOVED <br /> ❑6.TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doirg Business As) 3. FACILITY <br /> L. A.J ID# V1,4101013175 1. <br /> NEAREST CROSS STREET 4o1. FACII ITY OWNER TYPE 4.LOCAL AGENCY/DISTRICT* 4(P- <br /> �_ ❑1.CORPORATION ❑5.COUNTY AGENCY* <br /> BUSINESS ER 1.GAS STATION 3.FARM 0 5.COMMERCIAL 403. S(2.INDIVIDUAL ❑6.STATE AGENCY* <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR ❑6.OTHER [13.PARTNERSHIP ❑7.FEDERAL AGENCY* <br /> TOTAL NUMBER OF TANKS `N• Is facility on Indian Reservation 405• *If owner of UST is a public agency:name of supervisor of division,section or 406• <br /> REMAINING AT SITE or trust lands? office which operates the UST. (This is the contact person for the tank records.) <br /> ❑Yes (KNo <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAMF,, 407• PHONE 408. <br /> MAILING OR STRE�ADD, SS ��� 409.CITY 0 ,, t `P 410. ST TE 411, 1 ZIP CODE qq 412. <br /> 3 t� <br /> PROPERTY OWNER TYPE LJI.CORPORATION R2.INDIVIDUAL 4.LOCAL AGENCY/DISTRICT LJ6.STATEAGENCY 413. <br /> ❑3.PARTNERSHIP [15.COUNTY AGENCY ®7.FEDERAL AGENCY <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME414. PHONE 415. <br /> MAILING OR STREET ADDRESS 416• <br /> Le <br /> CITY 417. STATE/ 418. ZIP C E 419. <br /> V� k 1-� sT L <br /> TANK OWNER TYPE 1.CORPORATION 2.INDIVIDUAL 4.LOCAL AGENCY/DISTRICT 6.STATE AGENCY 420. <br /> 3.PARTNERSHIP Q 5.COUNTY AGENCY 7.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY TK HQ 44- 1 1 1 1 1 1 1 Call 916 322-9669 if questions arise 421. <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ❑1.SELF-INSURED ❑4.SURETY BOND ❑7.STATE FUND ❑10.LOCAL GOVT MECHANISM 4r- <br /> 2.GUARANTEE ❑5.LETTER OF CREDIT 0.8.STATE FUND&CFO LETTER ❑99.OTHER: <br /> INSURANCE ❑6.EXEMPTION .STATE FUND&CD <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one box to indicate which address should be used for legal notifications and mailing. <br /> Legal notifications and mailings will be sent to the tank owner unless box I or 2 is checked. 1A I.FACILITY [12. PROPERTY OWNER [13.TANK OWNER 423• <br /> VII.APPLICANT SIGNATURE <br /> Certification: I • that the information provided in is true and accurate to the best of my knowledge. <br /> SIGNATURE Of qPLICANT DATE 424• PHONE a25. <br /> ?, 0 ' <br /> NAME F APPL ANT(Print) 426• TITLE 0EAPPLICANT 4-77. <br /> F=►(2 <br /> STATE UST FACILITY NUMBER(Agency uce only) 428• 1998 UPGRADE CERTIFICATE NUMBER(Agency use only) 41-9 <br /> (See Data Element 1,above. <br /> UPCF Hwfwre-a(1/99)-1/2 http://www.unidocs.org Rev.02/16/00 <br />