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UNIFIED PROGRAM CONSOLIDATED FORM O Gj <br /> TANKS n V <br /> UNDERGROUND STORAGE TANKS - FACI <br /> (One page per site) Page_of <br /> TYPE OF ACTION 1.NEW PERMIT ❑3.RENEWAL PERMIT5.CHANGE OF INFORMATION ❑7.PERMANENTLY CLOSED SITE 400• <br /> (Check one item only) ❑4.AMENDED PERMIT (Specify c&nge) ❑8.TANK REMOVED <br /> ❑6.TEMPORARY SITELOSURE <br /> T�tj Mr Cr' TI FAC ITY/SITE INFORMATION <br /> BUS ENE SS NAME(Same as FAcmn-y NAME or DBA-DdvgBusineso As) 3, FACILITY <br /> N w►�� LFhvE ©i L ID# 1 CA 1. <br /> NEAREST CROSS STREET 401. FACILITY OWNER TYPE 4.LOCAL AGENCY/DISTRICT* 402. <br /> X1.CORPORATION ❑5.COUNTY AGENCY* <br /> BUSINESS 1.GAS STATION 3.FARM 5.COMMERCIAL 403• [12.INDIVIDUAL ❑6.STATE AGENCY* <br /> TYPE ❑2.DISTRIBUTOR [14.PROCESSOR ❑6.OTHER [13.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 /> R ❑Yes k No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407• PHONE 408. <br /> I� m E2 � ��Pt=n7 TNvr-� U-� 9� - o i o <br /> MAILING OR STREET ADD SS r� 409. <br /> 872$ 7HO(W?null J1, <br /> CITY ( o C A) 410• STATEZIP CODE'7 <br /> S ZD 7 412. <br /> PROPERTY OWNER TYPE 1.CORPORATION 2.INDIVIDUAL L1 4.LOCAL AGENCY/DISTRICT Ll 6.STATE AGENCY 413. <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> III.TANK OWNER INFORMATION <br /> TANK O ER NAME 41a. PHONE 415. <br /> "Ammetz is Pm-1 Tmves-i a -s L ,z©� <br /> (..An <br /> MAILING OR STREET ADDRESS 416. <br /> CITY � J4t7. 1 STATE ahs. 1 ZIP CODE ��ZO � 419. <br /> TANK OWNER TYPE i 1.CORPORATION ❑2.INDIVIDUAL 4.LOCAL AGENCY/DISTRICT 6.STATE AGENCY ago. <br /> [13.PARTNERSHIP 5.COUNTY AGENCY 0 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 /> pENo � 2 20(U-1 V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ❑1.SELF-INSURED ❑4.SURETY BOND ❑7.STATE FUND ❑10.LOCAL GOVT MECHANISM 422 <br /> ❑2.GUARANTEE ❑5.LETTER OF CREDIT tj�g.STATE FUND&CFO LETTER ❑99.OTHER: <br /> [13.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 sem to the tank owner unless box 1 or 2 is checked ❑ 1.FACILITY ry <br /> 2. PROPERTY OWNER [:13.TANK OWNER 423. <br /> VII.APPLICANT SIGNATURE <br /> Certification: I certify that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNATUREOF APPLI DATE <br /> T azo. PHONE 425. <br /> g/�J d� <br /> NAME OF APPLICANT(print) 426. TITLE OF APPLICANT 427. <br /> ,VM 4 ti S- G u OLI •�c�-� <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 Hwfwre-a(1/99)-1/2 http://www.unidocs.org Rev.02/16/00 <br />