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JUN 13 2006 9: 03AM HLASERJET 3200 p. 2 <br /> UNIFIED PROGRAM 1 CONSOLIDATED FORM OC <br /> `D� <br /> UNDERGROUND STORAGE TANKS-FACILITY to i�'�L <br /> (One page per site) Page_of <br /> TYPE OF ACTION ❑I.NEW PERMIT ❑3.RENEWAL PERMITS.CHANGE OF INFORMATION 400. <br /> (Check one item only) [34.AMENDED PERMIT(Speci ie) ❑7.PERMANENTLY CLOSED SITE <br /> ❑8.TANK REMOVED <br /> ❑6.'TEMPORARY SITE CLOSU <br /> I. FACILITY/SITE INFORMATION <br /> BUSIN SNAME(Sa_iu,FAC[I.[TYNA- or DHA-DoirW]3 5;As) 3. 1 FACILITY <br /> ID# d o' z <br /> NEAREST CROSS STREET 401 FACILITY OWNER TYPE 4.LOCAL AGENCY/DISTRICT* 402. <br /> ❑L CORPORATION ❑5.COUNTY AGENCY* <br /> BUSAIESS 1.GAS STATION El 3-FARM ❑5.COMMERCIAL 403. *2.INDIVIDUAL ❑6.STATE AGENCY* <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR ❑6.OTHER ❑3.PARTNERSHIP ❑7.FEDERAL AGENCY* <br /> TOTAL NUMBER OF TANKS 404. Is facilityon Indian Reservation 405. "If owner of UST is a public agency:name of supervisor of divis[oa,section a 406 <br /> REMAINING AT SITE or trust lands? office which operates the UST. (This a the contact person Toa the lank records.) <br /> ❑Yes ®No <br /> IL PROPERTY OWNER INFO ATION <br /> PROPERTY OWNER, <br /> NAM) 4m. PHONE 408. <br /> -ARMIAW SNOW u 1 7 <br /> MAILING OR STREET ADDRESS acv <br /> t <br /> CITY1-94 Oto. STAT , 411. ZIP CODEQ/ 412,L _ <br /> PRO ERTY OWNER TYPE L1 L CORPORATION 2.INDIVIDUAL 4.LOCAL AGENCY/DISTRICT Lj 6.STATE AGENCY 413. <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> III.TANK OWNER INFORMATION <br /> TAk4KOWN RNA " ala PHO 415. <br /> jeAj <br /> MAILLYG 0TREET ADDRESS 416, <br /> 7_$ 61/' Wg7 <br /> CTTY 6mk� <br /> 417. STAT�F,� als. ZIP CODE 419. <br /> �� Z/ <br /> f <br /> TANK OWNER TYPE El 1.CORPORATION 2,INDIVIDUAL 0 4.LOCAL AGENCYlDISTRICT 6.STATE AGENCY azo. <br /> 3.PARTNERSHIP 5.COUNTY AGENCY 7.FEDERAL AGENCY <br /> IY.BOA:RD Of EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY K HQ 44- L Call 916 322-9669 if quesdons arise 421 <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ❑1.SELF-INSURED ❑4.SURETY BOND ❑7.STATE FUND <br /> E]2.GUARANTER El 5.LETTER OF CREDIT [110.LOCAL GOVT MECHANISM 422❑3.INSURANCE 6.EXEMPTION ❑8,STATE FUND&CFO LETTER TTF.R ❑99.OTHER: <br /> ❑9.STATE FUND.&CD <br /> VL LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Chack one box to indicate which address should be used for lagal notifications and mailing. <br /> legal notifications and mailings will be sent to the tank owner unless box I or 2 is checked, ❑ 1.FACILIPY ❑2. PROPERTY OWNER ❑3.TANK OWNER 423. <br /> VII.APPLICANT SIGNATURE <br /> Certifi •1 C04 that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNA APP DATE/ 4za. PHONE a2s. <br /> lP <br /> N P ANT(print) 4z6 TITLE O APPLICANT 427 <br /> p"-/-] ;i3z Q a(S" 40 Ld,S Ep <br /> STATE UST FACILITY NUMBER(.�ncytim ody) 428• 1998 UPGRADE CERTIFICATE NUMBER(Ageaeyuse ody) 429. <br /> (See Data Element 1,above. <br /> UPCF Hwfwre-a(1/99)-112 http://www.utaidocs.org Rev.07!16100 <br />