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-- <br /> J UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS -- FACILITY (one page per site <br /> Page of <br /> r 7.PERMANENTLY CLOSED Si <br /> TYPE OF ACTION r 3.RENEWAL PERMIT CHANGE OF INFORMATION(Specify change• r 8.TANK REMOVED 400 <br /> r 1 NEW SITE PERMIT � local use only) <br /> (Check ore item only) r 4.AMENDED PERMIT <br /> F 6.TEMPORARY SITE CLOSURE JA <br /> 1.FACILITY/SITE INFORMATION <br /> FACILITY 10 <br /> BUSINESS NAME(Same as FA <br /> CILITY NAME or DBA-Doing Business As) 3 <br /> # C <br /> GC b nN O + <br /> w IN FACILITY OWNER TYPE r 4. LOCAL AGENCY/DISTRICT' <br /> NEAREST CROSS STREET �1 I , , ;C r 1. CORPORATION r 5. COUNTY AGENCY` i <br /> 11-� %-1" �'�Q Vr INDIVIDUAL r 6. STATEAGENCY' <br /> BUSINESS TYPE r14-t'AS STATION F 3.FARM r 5.COMMERCIAL 3 PARTNERSHIP r 7. FEDERAL AGENCY' 4,02 <br /> r 2.DISTRIBUTOR r 4.PROCESSOR r 6.OTHER <br /> THE <br /> Is facility on Indian Reservation or 'If owner of UST is a public agency:name of supervisor of <br /> TOTAL NUMBER OF TANKS division,section or office which operates the UST. <br /> trustlands? <br /> REMAINING AT SITE 2 `/, (This is the contact person far the tank records.) <br /> 404 r Yes r No 405 <br /> 406 <br /> II.PROPERTY OWNER INFORMATION PHONE 408 q 1 <br /> PROPERTY OWNER NAME 407 0 102 7 7 v <br /> MAILING OR STREET ADDREO 409 �� �� t C 61 Ot S 2 L <br /> 2 g o h \f a G a y rT STATE 411 ZIP CODE 412 <br /> CITY\ 410 `1 4 c� I <br /> O 0 C F 4 LOCAL AGENCY/DISTRICT r 6 STATE AGENCY et 3 i <br /> PROPERTY OWNER TYPE r 2. INDIVIDUAL r S. COUNTY AGENCY r 7. FEDERAL AGENCY <br /> r 1. CORPORATION PARTNERSHIP <br /> III.TANK OWNER INFORMATION PHONE 415 Q <br /> TANK OWNER NAME 414 -I ) [V- o` , 7 <br /> S � "U*-1 S%A 'rl <br /> MAILING OR STREET ADDRESS 416 -21 <br /> a 0 f a g y 1 a �� STATE 418 ZIP CODE 419 <br /> C-.� <br /> CITY 417 <br /> 417 4f--A2 4 b <br /> Q C> F 4. LOCAL AGENCY 1 DISTRICTSTATE AGENCY e2C <br /> TANK OWNER TYPE r 2. INDIVIDUAL r 7. FEDERAL AGENCY <br /> r 1 CORPORATION j !'PARTNERSHIP r 5 COUNTY AGENCY <br /> I <br /> 421 ! <br /> TY(TK)HQ 4 4 Call(916)322-9669 if questions arise <br /> r7. sT TE FUND r 10. LOCAL GOV=T MECHANISM <br /> INDICATE METHOO(S) r 1. SELF-INSURED r 4. SURETY BOND I TE FUND&CFO LETTER r 99. OTHER: 422 <br /> r 2. GUARANTEE r 5. LETTER OF CREDIT r g STATE FUND a CD <br /> r 3. INSURANCE r 6. EXEMPTION <br /> Check one box to indicate which address should be used for legal notifications and mailing. r 1. FACILITY OWNER 423 <br /> r 2. PROPERTY OWNER F 3. TANK <br /> e al notifications and e sent to the tank owner unless box 1 r is checked. <br /> mailin s will b <br /> _ 425 <br /> Certification: I certify that the information provided her in is We and accurate to the best of my knowledge.DATE O O 424 PHON J 0 q S 7-7SIGNATURE OF APPLICANT <br /> i � ) Q L <br /> TITLE OF PLICA � p 427 <br /> NAME OF APPLICANT(print ' x, <br /> `j l SIG, <br /> 428 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 <br /> STATE UST FACILITY NUMBER(For kxal use only) <br /> 5 Formerly SWRCB Fora <br /> UPCF(1199 revised) <br />