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UNIFIED PROGRAM CONSOLIDATED FORM <br /> ' TANKS <br /> UNDER&OUND STORAGE TANKS - ACILITY <br /> (One page per site) Page.-of <br /> TYPE OF ACTION ❑1.NEW PERMIT [13.RENEWAL PERMIT 5.CHANGE OF INFORMATION ❑7.PERMANENTLY CLOSED SITE 400. <br /> (Check one item only) ❑4.AMENDED PERMIT (Specify change) <br /> ❑8.TANK REMOVED <br /> ❑6.TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION 206 JUL 18 Am `1 21i <br /> . <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3, FACILITY <br /> D# �402.NEAREST CROSS STREET 401. FACILITY OWNER TYPE 4.LOCAL AGENCY/DISTRICT* <br /> b- A 1.CORPORATION ❑5.COUNTY AGENCY* <br /> BUSINESS ❑ .GAS STATION ❑3.FARM 5.COMMERCIAL ao3. ❑2.INDIVIDUAL ❑6.STATE AGENCY* <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR X 6.OTHER ❑3.PARTNERSHIP [17.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 /> I ❑Yes FNo <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 408 <br /> MAILING OR STREET ADDRESS <br /> e 409 <br /> L/hn �� <br /> CITY alo. STATE alt. ZIP CODE j� 41z <br /> It l� <br /> PROPERTY OWNER TYPE 1.CORPORATION 2.INDIVIDUAL 4.LOCAL AGENCY/DISTRICT 6.STATE AGENCY 413. <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE <br /> 415, <br /> MAILING OR STREET ADDRESS <br /> 416. <br /> v <br /> CITY a17. STATE als. ZIP CODE 419 <br /> 5 (� <br /> TANK OWNER TYPE Al.CORPORATION ❑2.INDIVIDUAL 0 4.LOCAL AGENCY/DISTRICT Ll 6.STATE AGENCY ,120. <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 p Call 916 322-9669 if questions arise 421 <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) .l.SELF-INSURED ❑4.SURETY BOND [17.STATE FUND ❑10.LOCAL GOVT MECHANISM <br /> ❑2.GUARANTEE ❑5.LETTER OF CREDIT ❑8.STATE FUND&CFO LETTER ❑99.OTHER: 422. <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 ❑2. PROPERTY OWNER P(3.TANK OWNER 423. <br /> VII.APPLICANT SIGNATURE <br /> Certification: I certify that the informatiln provided herein is true and accurate to the best of my knowledge. " <br /> SIGNATURE OF APPLICAN t ATE azo. PHONE 425 <br /> NAME OF APPLICANT(print) DD 426. TITLE OF APPLICANT 427 <br /> STATE UST FACILITY NUMBERA enc use only) QV 428. <br /> t g y 1998 UPGRAD CERTIFIC E NUMBER(Agency use only) 429 <br /> (See Data Element 1,above. <br /> UPCF Hwfwrc-a(1/99)-1/2 http://www.unidocs.org Rev.02/1F <br />