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t UNIFIED PROGRAM CONSOLIDATED FO M <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> na (one page per site) <br /> Page _ of _ <br /> TYPE OF ACTION INEW SITE PERMIT r 3.RENEWAL PERMIT 5.CHANGE OF INFORMATION(Spa than e- P T PERMANENTLY CLOSED SITE <br /> (Check one item only) r' I <br /> 4.AMENDED PERMIT local use only)PQ n� 1� � �,.L'� 8.TANK REMOVED 400 <br /> F 6.TEMPORARY SITE 6LOSURE <br /> I.FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Same as FACII ITY NAMF or DBA-Doing Business As) 3 FACILITY ID# <br /> 6�?LA Ick- -rv' <br /> NEAREST WOSS STREET FACILITY OWNER TYPE r 4. LOCAL AGENCY/DISTRICT- <br /> 0 1 h 1. CORPORATION F 5. COUNTY AGENCY <br /> BUSINESS TYPE GAS STATION F 3.FARM F 5.COMMERCIAL ri''`m IVIDUAL <br /> � <br /> ` I' 6. STATE AGENCY' <br /> F 2.DISTRIBUTOR F 4.PROCESSOR F 6.OTHER F-6 PARTNERSHIP r 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 r Yes Mlo 405 406 <br /> 11.PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407PHONE 408 <br /> L'tlxP, ,r� SIr��H ��i�cma <br /> MAILING OR STREET ADDRESS 409 <br /> 9NS �/�M,M�(z TSN <br /> CITY 410 STATE 411 ZIP CODE 412. <br /> 5'7mck�orl C� a r2ra <br /> PROPERTY OWNER TYPE F 2VIDUAL F 4. LOCAL AGENCY/DISTRICT F 6. STATE AGENCY 413 <br /> I 1. CORPORATION 3.. IPARTNERSHIP F 5. COUNTY AGENCY F 7. FEDERAL AGENCY <br /> - 111.TANK OWNERINFORMATION <br /> TANK OWNER NAME 414PHONE,r`<r,J -Dh(LC0rf PHONE 415 5-g- (6,/ <br /> MAILING OR STREET ADDRESS 416 <br /> ) 5- -r 1a <br /> CITY 417 STATE 418 ZIP CODE 419 <br /> STGFCTN 11 '?5-2-1 <br /> TANK OWNER TYPE r 2. IVIDUAL I' 4. LOCAL AGENCY/DISTRICT I'6. STATE AGENCY 420 <br /> I 1. CORPORATION 3. PARTNERSHIP I 5. COUNTY AGENCY F 7. FEDERAL AGENCY <br /> TY(TK)HO 4 4 1 - I I I I I I I Call(916)322-9669 if questions arise 421 <br /> INDICATE METHOD(S) F 1. SELF-INSURED F 4. SURETY BOND P 7. TATE FUND I 10. LOCAL GOV=T MECHANISM <br /> F 2 GUARANTEE F 5. LETTER OF CREDIT STATE FUND&CFO LETTER F 99. OTHER: <br /> r 3. INSURANCE r 6. EXEMPTION r 9. STATE FUND&CD 422 <br /> Check one box to indicate which address should be used for legal notifications and mailing. 1. FACILITY r 2. PROPERTY OWNER r 3. TANK OWNER 423 <br /> Le al notifications and mailin s will be sent tot the tank owner unless box 1 or 2 is checked. <br /> 11 APPI ICANT SIGNATURE <br /> Certification: I certify that the informati f <br /> provided herein is true an a e to the best of my knowledge. 4v. ic <br /> SIGNATURE OF APPLICANT "'� DATE m c:J 424 PHONE,��` G 5•.5 ©60 425 <br /> NAME OF APPLICANT(printe-1-119R R 1 r - s/��# l /O./ 426 TITLE OF APPLICANT©�� „427 �l <br /> STATE UST FACILITY NUMBER(For local use only) L G. /`� 42111998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 <br /> UPCF(1/99 revised) 5 Formerly SWRCB Form A <br /> (,� qlAIDD <br />