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UNIFIED PROGRAM CONSOLIDATED F M <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY 4 <br /> (one page per site) <br /> Page _ of I <br /> TYPE OF ACTION r 1.NEW SITE PERMIT F 3.RENEWAL PERMIT r 5.CHANGE OF INFORMATION( �� 9S chan e- F 7.PERMANENTLY CLOSED E <br /> (Check one item only) <br /> I 4.AMENDED PERMIT local use only) F 8.TANK REMOVED 400 <br /> r 6.TEMPORARY SITE CLOSURE <br /> 1000 f,i CAagk IV. 1.FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 FACILITY t0#Skvru Ss nP * JFA 7 <br /> NEAR TCR S TREET�. q 40 FACILITY OWNER TYPE r 4. LOCAL AGENCY/DISTRICT' <br /> Me WS F 1. CORPORATION COUNTY AGENCY` <br /> BUSIN SS TYPE F 1.GAS STATION F 3.FARM F 5.COMMERCIAL Y 2. INDIVIDUAL <br /> I' 6. STATE AGENCY' <br /> F 2.DISTRIBUTOR F 4.PROCESSOR ;<6.OTHER F 3. PARTNERSHIP F 7. FEDERAL AGENCY- 402 <br /> 403 <br /> TOTAL NUMBER OF TANKS Is facility on Indian Reservation or 'If owner of UST is a public agency:name of supervisor of <br /> REMAINING AT SITE ,, trustlands? division,section or office which operates the UST. <br /> �- (This is the contact person for the tank records.) <br /> 404 F Yes K. 405 406 <br /> II.PROPERTY OWNERINFORMATION <br /> PROPERTY OWNER NAME 407 IPHONE 408 <br /> MAILING OR STREtUDRESS Y 409 <br /> S " <br /> 4 <br /> Cry 410 STATE 411 ZIP CODE 412 <br /> V <br /> PROPERTY OWNER TYPE F 2. INDIVIDUAL F 4. LOCAL AGENCY/DISTRICT r 6. STATE AGENCY 413 <br /> F 1. CORPORATION r 3. PARTNERSHIP F 5. COUNTY AGENCY F 7. FEDERAL AGENCY <br /> Ill.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> S Dl a46 4q, <br /> MAILIN OR STREET S #16 <br /> CITY _�0 G � �� (:J+ ��C3 D ' STATE 418 ZIP CODE 419 <br /> TANK OWNER TYPE r 2. INDIVIDUAL r 4. LOCAL AGENCY/DISTRICT r 6. STATE AGENCY 420 <br /> r 1. CORPORATION r 3. PARTNERSHIP X5. COUNTY AGENCY F 7. FEDERAL AGENCY <br /> TY(TK)HQ 4 4 - r,ARn OE r 11 1 <br /> Call(916)322-9669 if questions arise 421 <br /> INDICATE METHOD(S) r 1. SELF-INSURED IF 4. SURETY BOND' IF 7 STATE FUND t 10. LOCAL GOV=T MECHANISM <br /> F 2. GUARANTEE r 5. LETTER OF CREDIT �**. STATE FUND&CFO LETTER I 99. OTHER: <br /> r 3. INSURANCE r 6. EXEMPTION F 9. STATE FUND&CD 422 <br /> Check one box to indicate which address should be used for legal= <br /> and mailing. r' i. FACILITY ' r 2. PROPERTY OWNER TANK OWNER 423 <br /> al n t fications and mas will sent to thetank ow les x 1 r i <br /> VII ARRI ICANI SIGNATURE <br /> Certification: I certify that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNATURE OF APPLICANT DATE 424 1 PHONE 425 <br /> NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 427 <br /> 77T FACILITY NUMBER(For local use only) 428 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 <br /> 5 © <br /> Q i <br /> UPCF(1/99 revised) 10'1 6 DFormerly SWRCB Form A <br />