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1 <br /> • UNIFIED PROGRAM CONSOLIDATED FO <br /> l TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (One page per site) Page of <br /> TYPE OF ACTION [11.NEW PERMIT ❑3.RENEWAL PERMIT .CHANGE 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 /> I. FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Sae as FACILITY NAME or DBA-Doing Business As) 3. 1 FACILITY <br /> 2551iI' #060 1. <br /> NEAREST CROSS STREET '�'". ` 401. FACT TY OWNER TYPE ❑4.LOCAL AGENCY/DISTRICT* 402. <br /> S-k 14 1.CORPORATION ❑5.COUNTY AGENCY* <br /> BUSINESS ff I.GAS STATION ❑3.FARM ❑5.COMMERCIAL 403. ❑2.INDIVIDUAL [:16.STATE AGENCY* <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR [:16.OTHER ❑3.PARTNERSHIP ❑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 /> 'Q/� ❑Yes 9 No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. NE 408. <br /> Is v%cs r Rd1 a( s-C.IDIF 11 LLC, L"�►o769 L4 Stoo <br /> MAILING OR STREET ADDRESS 409. <br /> CITY 410. STATE 411. ZIP CODE 412, <br /> Los e\'Q-5 CRoOzs <br /> PROPERTY OWNER TYPE l�CORPORATION ❑2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT [:16.STATE AGENCY 413. <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> MAILING OR STREET ADDRESS 416. <br /> CITY 418. ZIP CODE 419, <br /> TANK OWNER TYPE ❑ 1.CORPORATION ❑2.INDIVIDUAL ❑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 /> 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) SELF-INSURED ❑4.SURETY BOND ❑7.STATE FUND ❑10.LOCAL GOVT MECHANISM 411 <br /> ❑2.GUARANTEE ❑5.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 wiless box I or 2 is checked. [:11.FACILITY Lr1 L. PROPERTY OWNER ❑3.TANK OWNER 423. <br /> VII.APPLICANT SIGNATURE <br /> Certification: I c fy that the' fon tion ided herein is,true and accurate to the best of my knowledge. <br /> SIGNATU AN DATE 424. PHONE 425. <br /> 1a-2-1-oS" K, 4 4-Sl07 <br /> NAME OF PLICANT(print) 426. TITLE OF APPLICANT 427. <br /> his W ovvim Sev`:er vice, C�►dRvat <br /> STATE UST FACILITY NUMBER(Agency use only) 428. 1998 UPGRADE CERTIFICATE NUMBER(Agency use only) 721 <br /> (See Data Element 1,above. <br /> UPCF Hwfwrc-a(1/99)-1/2 http://www.unidocs.org Rev.02/16/00 <br />