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............................ <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY l lel <br /> (one page pe <br /> Page _ of _ <br /> TYPE OF ACTION r 7.PERMANENTLY CLOSED SITE <br /> (Check one item only) 1.NEW SITE PERMIT r 3.RENEWAL PERMIT r 5.CHANGE OF INFORMATION(Specify change- ^ <br /> r 4.AMENDED PERMIT local use only) r 8.TANK REMOVED 400 <br /> r 6.TEMPORARY SITE CLOSURE <br /> I.FACILITY/SITE INFORMATION Z/ <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 FACILITY to A <br /> �� . <br /> NEAREST C OSS STREET' 401 FACILITY OWNER TYPE r 4. LOCAL AGENCYIDISTRICT• <br /> r 1. CORPORATION r 5. COUNTY AGENCY- <br /> BUSINESS TYPE r 1.GAS STATION r 3.FARM r S.COMMERCIAL r 2. INDIVIDUAL <br /> STATE AGENCY' <br /> r 2.DISTRIBUTOR r 4.PROCESSOR <6.OTHER r 3. PARTNERSHIP 41 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 YNo 405 406 <br /> II.PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408 <br /> l << v <br /> MAILING OR STREET ADDRESS 409 <br /> .-I. �.� `mo i' S.- <br /> 4 <br /> CITY 410 d STATE411ZIP CODE 412 <br /> 1 yl <br /> PROPERTY OWNER TYPE r 2. INDIVIDUAL r 4. LOCAL AGENCY/DISTRICT X6. STATE AGENCY 413 <br /> r 1. CORPORATION r 3. PARTNERSHIP r 5. COUNTY AGENCY r 7 FEDERAL AGENCY <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER E 414 / PHO E 415 <br /> MAILING OR STREET ADORES 4116 w <br /> CITY 417 STATE 418 ZIP CODE 419 <br /> TANK OWNER TYPE r 2. INDIVIDUAL r 4. LOCAL AGENCY/DISTRICT Jv_8 STATE AGENCY 420 <br /> r 1. CORPORATION r 3. PARTNERSHIP r 5. COUNTY AGENCY r 7. FEDERAL AGENCY <br /> TY(TK)HQ 4 4 Call(916)322-9669 if questions arise 421 <br /> INDICATE METHOD(S) r 1. SELF-INSURED r 4. SURETY BOND r 7. STATE FUND r 10. LOCAL GOV=T MECHANISM <br /> r 2. GUARANTEE r �` LETTER OF CREDIT r 8. STATE FUND 8 CFO LETTER r 99. OTHER: <br /> r 3. INSURANCE EXEMPTION r 9. STATE FUND 8 CD 422 <br /> Check one box to indicate which address should be used for legal notifications and mailing. r 1. FACILITY 2. PROPERTY OWNER r 3. TANK OWNER 423 <br /> e al not fca ionand <br /> n m ilio swill De sen to the tank er unless box 1 or 2 is checked, <br /> V11 ARPI ICANT SIGNATURE <br /> Certification: I certify that the ierein is true and accurate to the best of my knowledge. <br /> SI p DATE 424 PHONE _ 25 <br /> o 1Com ) <br /> N AP CAN ( ) 426 TITLE F APPLICANT 427 <br /> ZLA <br /> Ili Ili <br /> STATE UST FACILITY NUMBER(For local use only) 4211 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 <br /> UPCF(1/99 revised) 5 Y <br /> Formed SWRCB Form A <br />