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a� <br /> r' UNIFIED PROGRAM CONSOLIDATED F79M <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page per site) <br /> Page _ of _ <br /> TYPE OF ACTION I 1.NEW SITE PERMIT F 3.RENEWAL PERMIT I' 5.CHANGE OF INFORMATION(Specify change- I T PERMANENTLY CLOSED SITE <br /> (Check one item only) l ocause only) F 8.TANK REMOVED 400 <br /> I' 4.AMENDED PERMIT lO <br /> F 6.TEMPORARY SITE CLOSURE <br /> L FACILITY/SITE INFORMATION <br /> BUSINESS1AANVE(Same as FACILITY NAME or DBA-Doing Business As) 3 FACILITY to# <br /> �vK� Iv ►vvl �;�. <br /> NEAREST CROSS STREET 401 FACILITY OWNER TYPE I 4. LOCAL AGENCY/DISTRICT- <br /> IF 1. CORPORATION I 5. COUNTYAGENCY' <br /> BUSINESS TYPE1.91*1*1.GAS STATION I 3.FARM I 5.COMMERCIAL IF 2. INDIVIDUAL <br /> 7-� I, 6. STATE AGENCY' <br /> r 2.DISTRIBUTOR r 4.PROCESSOR r 6.OTHER /' PARTNERSHIP I- 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 2. F Yes ' no 405 406 <br /> IL PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 4071 PHONE 408 <br /> S k h i rI h a n -Dh rL - <br /> MAILING OFJ STBEET ADDRESS 409 <br /> IC145 4am m w✓L <br /> CITY 410 STATE 411 ZIP CODE 412 <br /> PROPERTY OWNER TYPE I 2. INDIVIDUAL I 4. LOCAL AGENCY/DISTRICT F 6. STATE AGENCY 413 <br /> F 1. CORPORATION PARTNERSHIP I' 5. COUNTY AGENCY F 7. FEDERAL AGENCY <br /> III.TANK OWNER INFORMATION' <br /> TANK OWNER NAME @14 % PHONE 415 <br /> MAILING OR STREET ADDRESS - 416 <br /> S. E Do►ra.d.� <br /> CITY 417 STATE 418 ZIP CODE 419 <br /> C -/ <br /> TANK OWNER TYPEI�'.,�2. INDIVIDUAL I' 4. LOCAL AGENCY/DISTRICT I6. STATE AGENCY 420 <br /> I 1. CORPORATION <br /> VIS. PARTNERSHIP F 5. COUNTY AGENCY I' 7. FEDERAL AGENCY <br /> TY(TK)HQ 4 4 rIARD GE E Call(916)322-9669 if questions arise 421 <br /> INDICATE METHOD(S) I 1. SELF-INSURED I 4. SURETY BOND I'7 STATE FUND r 10. LOCAL GOV=T MECHANISM <br /> I 2. GUARANTEE I 5. LETTER OF CREDIT X08 STATE FUND&CFO LETTER r 99. OTHER: <br /> I 3. INSURANCE I 6. EXEMPTION h 9. STATE FUND&CD 422 <br /> 12�5 <br /> box to indicatewhichaddreas should be used for legal notifications and mailing. I' 1. FACILITY IF 2. PROPERTYOWNER r 3. TANK OWNER 423 <br /> cations and ma=d <br /> sent tot k unlessx 1 or is checked <br /> 911 A PEN ICA NT SIGNAII IRE <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 /> STATE UST FACILITY NUMBER(Forlocal use only) 428 1998 UPGRADE CERTIFICATE NUMBER(Forlocal use only) 429 <br /> f-11 3735 (01zt*)0PN <br /> UPCF(1/99 revised) 5 Formerly SWRCB Form A <br />