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UNIFIED PROGRAM CONSOLIDATED FORM <br />TANKS <br />UNDERGROUND STORAGE TANKS - FACILITY <br />(one page per site) Page _ of <br />TYPE OF ACTION ❑ I. NEW SITE PERMIT ❑ 3. RENEWAL PERMITS.CHANGE OF INFORMATION El7.PERMANENTLY CLOSED SITE <br />(Check one item only) ❑ 4. AMENDED PERMIT specify change local use only ❑ 8. TANK REMOVED <br />❑ 6.TEMPORARY SITE CLOSURE 400 <br />I. FACILITY / SITE INFORMATION P ! r e2 <br />BUSINESS NAME (Same as FACILRY NAME or DBA-Doing Business As) 3 <br />FACILITY ID# <br />wk.rjoo'm <br />C.M <br />717T <br />T <br />1 <br />NEAREST CROSS STREET '1,',� �I • y�nti�l ✓ I .pQ1 <br />FACILITY OWNER TYPE 4. LOCAL AGENCY/DISTRICT' <br />Q/ lJ� 1j� I <br />❑ I. CORPORATION ❑ 5. COUNTY AGENCY* <br />❑ 2. INDIVIDUAL ❑ 6. STATE AGENCY* <br />B SIN SS 1. GAS STATION Ll 3. FARM ❑ 5. COMMERCIAL <br />TYPE [12. DISTRIBUTOR ❑ 4. PROCESSOR ❑ 6. OTHER 4o3 <br />❑ 3. PARTNERSHIP ❑ 7. FEDERAL AGENCY' 4t12 <br />TOTAL NUMBER OF TANKS <br />Is facility on Indian Reservation or <br />•If owner of UST is a public agency: name of supervisor of division, section or office which <br />REMAINING AT SITE <br />trustlands? <br />operates the UST (This is the contact person for the tank records.) <br />404 <br />❑ Yes No 4M <br />406 <br />II. PROPERTY OWNER INFORMATION <br />PROPERTY OWNER 407 <br />PHONE 408 <br />]N9AMEE <br />�. VN <br />_ c w <br />MAILING OR STREET AD RESS 409 <br />oC 3 LCL d V ' <br />CITY 410 <br />STATE 411 <br />ZIP CODE ate <br />194 C <br />PROPERTY OWNER TYPE U 1. CORPORATION 2, INDIVIDUAL El 4. LOCAL AGENCY/ DISTRICT 6. STATE AGENCY <br />❑ 3. PARTNERSHIP [15. COUNTY AGENCY ❑ 7. FEDERAL AGENCY 413 <br />III. TANK OWNER INFORMATION <br />TANK OWNER NAME 414 1 PHONE 415 <br />C) <br />1AILING ORSTRE ADDRESS 416 <br />417 <br />STATE alb <br />ZIP CODE 419 <br />rTA <br />9 _.� <br />. CORPORATION 2. INDIVIDUAL ❑ 4. LOCAL AGENCY / DISTRICT Lj 6. STATE AGENCY ago <br />[13. PARTNERSHIP [15. COUNTY AGENCY ❑ 7. FEDERAL AGENCY <br />IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br />TY TK HQ 44- Cj Call 916 322-9669 if questions arise 421 <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br />INDICATE METHOD(s) D ❑ 4. SURETY BOND ❑ 10. LOCAL GOVT MECHANISM <br />❑ 2. GUARANTEE ❑ 5. LETTER OF CREDIT Iq 8. STATE FUND & CFO LETTER ❑ 99. OTHER: <br />❑ 6. EXEMPTION ❑ 9. STATE FUND & CD 422 <br />VI. LEGAL NOTIFICATION AND MAILING ADDRESS <br />FChcck�icate which address should be used for legal notifications and mailing. <br />d mailings will be sent to the tank owner unless box 1 or 2 is checked. ❑ 1. FACILITY �2. PROPERTY OWNER ❑ 3. 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 />SIGNATURE =NT <br />DATE 424 <br />1 PHONE azs <br />NAME OF APPLI rint) 426 <br />TTfffOFkPPLICANT 427 <br />1 <br />STATE UST FACILITY NUMBER (For local use only) 429 <br />1998 UPGRADE CERTIFICATE NUMBER (For local use only) 429 <br />UPCF (1/99 revised) 8 Formerly SWRCB Form A <br />