Laserfiche WebLink
UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (One page per site) Page t__of <br /> TYPE OF ACTION ❑1.NEW PERMIT ❑3.RENEWAL PERMIT ❑S.CHANGE OF INFORMATION [17.PERMANENTLY CLOSED SITE 400. <br /> (Check one item only) 4.AMENDED PERMIT (Specify change) ❑8.TANK REMOVED <br /> 6.TEMPORARY SITE CLOSURE <br /> 42 Qz2 <br /> 34 3 QJ 1`n W_' L FACILITY/SITE INFORMATION <br /> BUSINESS N (Same as FACILITY NAME or DBA-Doing Business As) 3. FACILITY <br /> rl � c. Q �N ID# b 3 ISt. <br /> N AREST CROSS STREET 401. FACILITY OWNER TYPE ❑4.LOCAL AGENCY/DISTRICT* 402. <br /> 'X_{ a A D JR1.CORPORATION ❑5.COUNTY AGENCY* <br /> BUSINESS .GAS STATION [13.FARM [15.COMMERCIAL 403. ❑2.INDIVIDUAL ❑6.STATE AGENCY* <br /> TYPE [12.DISTRIBUTOR [:14.PROCESSOR ❑6.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 /> ❑Yes 52 tTo <br /> II. PROPERTY OWNER INFORMATION <br /> PROP Y OWNER NAME407 PHONE aos. <br /> Lt"- <br /> MA G O) ET AD1gSS 409. <br /> CITY 410. S TE 411. ZIP CO 412. <br /> PROPERTY OWNER TYPE,,,, .CORPORATION ❑2.INDIVIDUAL 4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 413. <br /> ❑3.PARTNERSHIP [:15.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> III.TANK OWNER INFORMATION <br /> TAN ER NAME 414. PHONE ^ 415. <br /> • 5 (c D <br /> MAILI O STREET ADDIjESS 416. <br /> CGS• M�"1 ti- <br /> CITY 417. STATE 418. ZIP4 0D?E_ � 419. <br /> TANK OWNER TYPE 911 CORPORATION ❑2.INDIVIDUAL ❑4. - <br /> LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 420. <br /> ❑3.PARTNERSHIP [15.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 1 0 7,1 Call 916 322-9669 if questions arise 421. <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ❑1.SELF-INSURED ❑4.SURETY BOND T".STATE FUND [:110.LOCAL GOVT MECHANISM <br /> 422 <br /> ❑2.GUARANTEE ❑5.LETTER OF CREDIT ❑8.STATE FUND&CFO LETTER ❑99.OTHER: <br /> ❑3.INSURANCE ❑6.EXEMPTION [19.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. M-11"FACILITY [12- PROPERTY OWNER ❑3.TANK OWNER 423. <br /> VII.APPLICANT SIGNATURE <br /> Certification:I certify that the informmlmrpmvide _rein is true and accurate to the best of my knowledge. <br /> SIGN AT DATE to/- 14:;o <br /> / aza. PHONE � bass <br /> NAME,ff APPLIC;ANT a26. TITLE OF LICANT 427. <br /> G -`- <br /> 2l Aj- L.'t nr <br /> STATE UST FACILITY NUMBER(Agency use only) 428- 1998 UPGRADE CERTIFICATE NUMBER(Agency use only) 429. <br /> (See Data Element 1,above. <br /> UPCF Hwfwrc-a(1/99)-1/2 http://www.unidocs.org Rev.02/16/00 <br />