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r-1 <br />a <br />UNIFIED PROGRAM CONSOLIDATED FORM <br />UNDERGROUND STORAGE TANKS - FACILITY <br />TANKS <br />(one page per site <br />rage _ ur _ <br />TYPE OF ACTION r 1. NEW SITE PERMIT F 3. RENEWAL PERMIT V-11". CHANGE OF INFORMATION (Specify change - r T PERMANENTLY CLOSED SITE <br />(Check one item only) I' 4. AMENDED PERMIT local use only) I' 8. TANK REMOVED 400 <br />IF 6. TEMPORARY SITE CLOSURE <br />I. FACILITY I SITE INFORMATION <br />BUSINESS NAME (Same as FACILITY NAME or DBA - Doing Business As) 3 <br />r­il�� M�,� <br />FACILITY ID # <br />A <br />14", <br />I <br />NEAREST CROSS STREET 401 <br />CCN7,6= <br />ACILITY OWNER TYPE F 4. LOCAL AGENCY/DISTRICT- <br />1. CORPORATION I- 5. COUNTY AGENCY` <br />F 2. INDIVIDUAL I' 6, STATE AGENCY - <br />r 3. PARTNERSHIP r 7. FEDERALAGENCY- 402 <br />BUSINESS TYPE 1 GAS STATION I' 3. FARM I'S. COMMERCIAL <br />I 2. DISTRIBUTOR I 4. PROCESSOR F 6. OTHER <br />403 <br />TOTAL NUMBER OF TANKS <br />REMAINING AT SITE <br />404 "� / ,O <br />Is facility on Indian Reservation or 'If owner of UST is a public agency: name of supervisor of <br />trustlands? division. section or office which operates the UST. <br />(This is the contact person for the tank records.) <br />F Yes XNo 405 406 <br />II. PROPERTY OWNER INFORMATION <br />PROPERTY OWNER NAME 407 <br />1�t-{limon( �E�21-,',E S I/\/L <br />PHONE 408 2dg /90G <br />MAILING OR STREET ADDRESS 409 <br />/60 S 5 - o S`(_ <br />CITY 410 <br />1 o G(L'7-o r4 1 <br />STATE 411 <br />-70'i <br />ZIP CODE 412. <br />::� S Z'd <br />PROPERTY OWNER TYPE I' 2. INDIVIDUAL I' 4. LOCAL AGENCY I DISTRICT I' 6. STATE AGENCY 413 <br />1. CORPORATION I 3. PARTNERSHIP I 5. COUNTY AGENCY I 7. FEDERALAGENCY <br />III. TANK OWNER INFORMATION <br />TANK OWNER NAME 414 <br />PHONE 415 <br />MAILING OR STREET ADDRESS 416 <br />CITY 417 <br />STATE 418 <br />ZIP CODE 419 <br />TANK OWNER TYPE r 2. INDIVIDUAL F 4. LOCAL AGENCY / DISTRICT I' 6. STATE AGENCY 420 <br />7\1 1. CORPORATION F 3. PARTNERSHIP F 5. COUNTYAGENCY I' 7. FEDERALAGENCY <br />TY (TK) HO 4 1 4 '(� Q Call (916) 322-9669 if questions arise 421 <br />INDICATE METHOD(S) 1 SELF-INSURED I 4. SURETY BOND I 7. STATE FUND I 10. LOCAL GOV=T MECHANISM <br />r 2. GUARANTEE I 5. LETTER OF CREDIT r 8. STATE FUND S CFO LETTER I 99. OTHER: <br />F 3. INSURANCE r 6. EXEMPTION F 9. STATE FUND & CD 422 <br />Check one box to indicate which address should be used for legalnotcations and mailing. 1. FACILITY I� 2. PROPERTY OWNER I� 3. TANK OWNER 423 <br />Leoal notifications and mailin s will be sent to the tank owner unless box 1 or 2 is checked. <br />Certification: I certify that the info provided herein is true and accurate to the best of my knowledge. <br />SIGNATURE OF APPLICANT <br />DATE2. %� 424 <br />PHJ_�� 425 <br />1 <br />NAME OF APPLICANT (print) / 426 <br />TITLE OF APPLICANT 427 <br />STATE UST FACILITY NUMBER (For local use only) 428 1998 UPGRADE CERTIFICATE NUMBER (For local use only) 429 <br />5 <br />UPCF (1/99 revised) <br />Formerly SWRCB Form A <br />