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0 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (One page per site) Page I <br /> of <br /> TYPE OF ACTION ❑1.NEW PERMIT ❑3.RENEWAL PERMIT WIICHANGE OF INFORMATION ❑7.PERMANENTLY CLOSED SITE 400. <br /> (Check one item only) ❑4.AMENDED PERMIT(Specify change) ❑8.TANK REMOVED <br /> ❑6,TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Same m FACILITY NAME or DBA-Doing Business As) 3. 1 FACILITY <br /> 255 tit-1 ' #Doo <br /> I 11T <br /> NEAREST CROSS STREET ''`` 401. FACI TY OWNER TYPE ❑4.LOCAL AGENCY/DISTRICT* 402. <br /> �-^�1� I q W.CORPORATION ❑'S.COUNTY AGENCY* <br /> BUSINESS 91.GAS STATION ❑3.FARM ❑5.COMMERCIAL, 403• ❑2.INDIVIDUAL ❑6.STATE AGENCY* <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR ❑6.OTHER ❑3.PARTNERSFIIP ❑7.FEDERAL AGENCY* <br /> 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. <br /> REMAINING AT SITE / or trust lands office which operates the UST. (This is the contact person for the tank records.) <br /> 'C/1~ <br /> E]Yes <br /> No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 409. <br /> °Su V C.e c %I LLC. D 69 4 .gtoe, <br /> MAILING OR STREET ADDRESS 409, <br /> l vo% �ls1 oe <br /> CITY 410. 1 STATE 411• ZIP CODE 412. <br /> t-c,.s o-&s ek , R®ozs <br /> PROPERTY OWNER TYPE Ltj r CORPORATION ❑2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 413. <br /> [13.PARTNERSHIP [15.COUNTY AGENCY [17.FEDERAL AGENCY <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> MAILING OR STREET ADDRESS 416. <br /> CITY 1 418, ZIP CODE 419. <br /> TANK OWNER TYPE ❑ 1.CORPORATION [-12.INDIVIDUAL ❑4,LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 420. <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY TIC HQ 44- Call 916 322-9669 ifquestions arise 421. <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) SELF-INSURED ❑4.SURETY BOND ❑7.STATE FUND ❑10.LOCALGOV'T MECHANISM 424 <br /> ❑2.GUARANTEE [15.LETTER OF CREDIT ❑8.STATE FUND&CFO LETTER ❑99,OTHER: <br /> ❑3.INSURANCE ❑6.EXEMPTION ❑9.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 1 or 2 is checked. ❑ 1.FACILITY N2. PROPERTY OWNER ❑3.TANK OWNER 423. <br /> VII.APPLICANT SIGNATURE <br /> Certification: I c fy that the fora nion ided herein is,true and accurate to the best of my knowled&c. <br /> SIGNATU F AP CAN DATE 424. PHONE 425. <br /> 1®- ,?1 W 07 <br /> NAME OF PPLICANT(print) 426. TITLE OF APPLICANT 427. <br /> MCN(Os �cAv"'M Se�:or Vice. �' kqv-\ <br /> STATE UST FACILITY NUMBER(Agency use only) 428. 1998 UPGRADE CERTIFICATE NUMBER(Agency use Doty) 429. <br /> (See Data Element 1,above. <br /> UPCF I-Iwfwre-a(1/99)-1/2 http://www.onidoes.org Rev.02/16/00 <br />