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01/08/2004 08:23 209468 FIFTH FLOOR0, PP,GE :_7
<br /> UNIFIED PROGRAM CONSOLIDATED FORM
<br /> TANKS
<br /> UNDERGROUND STORAGE TANKS-FACILITY
<br /> (One page per s te) Page-_ofmom 111'
<br /> m�®=WEMNNMR=__
<br /> TYPE OF ACTION 1.NEW PERMIT ❑3.RENEWAL PERMIT ❑5.CHANCE OF INFORMATION []7.PERMANENTLY CLOSED SITE. ;ot'.
<br /> (Check one 1wm only) 0 4.AMENDED PEP tAIT(Specify change) ©8.TANK REMOVED
<br /> ❑6.TEMPORARY SITE CLOSURE
<br /> 11i
<br /> 1 '!f( I II Il } I Il •1 , l I lYC tIP
<br /> BUSINEcn+
<br /> SSNAME(SaeisFACILITYNAME-orDEA-Doing DwiatzA-) 3, FACILITY
<br /> NEAREST CROSS STREET aur, FACILITY OWNER TYPE ❑4.LOCAL AGENCY/DTS,,RICT )z,
<br /> MAIV'T H F_Y "AD ❑I.CORPORATION ❑S.COUNTY AGENCY*
<br /> 9USINESS1.GAS STATION 0 3.FARM L]5.COMMERCIAL 40- 2,NDIVIDUAL ❑6.STATE AGENCY*
<br /> TYPE 2.DISTRIBUTOR ❑4.PROCESSOR ❑6.OTHER 3.PARTNERSHIP ❑7.frDERAL AGENCY*
<br /> TOTALNUA4BER OF TANKS 4(w• Is facility on Indian Rcacrvation 405. •If owner of UST is a public asancy:name of supervimr of divisiOnl section or �06.
<br /> REMAINING AT SITE Z Or trust lands? office which operates do UST. (This is the contact person for the tank records.)
<br /> ❑YeS VN,0
<br /> ' or �Y�o �vE� isakz'o
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<br /> PROPERTY OWNER NAME 01,17. PHONE
<br /> MAILING OR STREET ADDRESS 40,
<br /> 3 31-7 -FL-I NT M 0 N T a R-/v E-
<br /> CITY _ a10. STATE Ott• ZIP CODE qs.1 zi-p al-•
<br /> X10 S C A- _
<br /> PROPERTY OWNER TYPE 1.CORPORATION INDIVIDOALU 4.LOCAL AGENCY I DISTRICT 6.STATE AGENCY aia.
<br /> 3.PARTNERSHIP ❑5.COUNTY AGENCY [:17-FEDEPJI AGEI`CY
<br /> rrl 11111 11111{11111 ��.� (_t I( It1Y
<br /> M].,.'i „ill,1 t y�l t { t I,.:,1��1+1, bra' 6 1. '- -. ": , ... •.•• .,� ytl �..,,1,,d14, Il'�� �„ill Ikl�t l 1 _.� �iuJ.r.wr.,....
<br /> TANK OWNER NAME ata. PHONE 415.
<br /> -Jog bAI,3 6-TR-At-3 q-o 8 6' (-0&0 ---
<br /> MAILING OR STREET ADDRESS ars,
<br /> CITY 417. STATE 418. $IP CODE ^, � p a1�.
<br /> SAN c10S 6, t�f o
<br /> TANK OWNER TYPE ❑1.CORPORATION 2.INDIVIDUAL Q 4.LOCAL AGENCY/DISTRICT [16,STAT) AGENCY 4+).
<br /> ❑3 PARTNERSHIP ❑5 COUNTY AGENCY 7 FEDER AL AGFNCY
<br /> ,�i'1i Jl !'1�j n{Il ,I II(II ^-.f''•I .. ��"- 'A■.FIIf .J,.'�:, ll (^'':Q+'�'1 �((•yylYroi�Yll,l 1„)l n,/.''1,•lc/l�iN'�y 11'�Ny-I(I f l lly'�'�''�'ly'�lS�l 1 1 I 1 I �,� ll:, tai:
<br /> E ^' ^'""^^�"���^ „l.o, c�,..„uo..n ata rc•pl� ,l l,u I,l.0 a >..ml 1 n l l 1„i. !iJ`_ •
<br /> TY K H 44 Call 916 322-9669 Lf uestlons anse a'1
<br /> �IX1{`� '�r /5 $'
<br /> I Otl' r ST'FWX X1�'�. AC'9i/1V�7I��.AJ'I 11 r i • ,I 1111 1 111 1 ,C:
<br /> 11 �"r-- ..., -". - ::vl,. "• l 119.LOCAL MECHADTSbII}
<br /> -
<br /> INDICATE METHOD(s) ❑I SELF INSURED 4.SURETY GOND 7.STATE FUND ❑ '4:•t+
<br /> ❑2.GUARANTEE ❑5.LETTER OF CREDIT 8.STATE FUND&CFO LETTER CJ 9 --
<br /> ll ®3.INSURANCE ❑.6.EXEMPTION ❑9.STATE FUND&CD
<br /> -,'� r -��, 't' :,,,:: '.`..'..,u� .11,1 �,��I VI L��U'��,I���i'I`'r.-l�io�t�i����� flsr>���ilC�ss(i.�i,{I�{n of e�{.n�11{ 1�r�•l f: ��---
<br /> •Cheek one box to indicate whieb address should be used for legal notifications and mailing, 4231
<br /> Legal notifications and mailings will be sent to the tank owner unless box 1 ort is checked. ❑ 1.FACILITY 2. PROPERTY OWNER ❑3.TANK OWNER
<br /> {• a �]� /'�`....gyp,�•�(Y �uqT �1 r ,
<br /> LICAIN:H �7.i.V ^IPP (' f I 1 1 l 1',q 11 1( 1)l 1 1 4 f 11 I rflirl i' .1111111111fllll 11 1 1 "•f 11 11 O,1 „�I l 1,,,i . ' { �J�•q„ '1 •,' - 1=1..
<br /> 11 ,f,l
<br /> f.l ' I•.�,u L(,.,,lt 1b1011 {11 ( :1,
<br /> Certification:li c 'fy thut the information provided herein is tnw and accurate to the best of my knowk c.
<br /> SI
<br /> =APPLICANT DATE nRywk
<br /> a:'-'.
<br /> A,- :== 03 It/6±_ `-o off_��:W
<br /> NAME OF APPLICANT(p• )
<br /> rz5. TITLE APPLI ANT
<br /> STATE UST rACiLITY NUIvIHER(Agency use only) 428. 1998 UPGRADE CER TATE NUMBER(ngencyuse m h) °'"
<br /> (See Data Element 1,above. -®_,-
<br /> UPCF Hwhivre-a(1/99)-112 http://wwW.anidoca aeg Rev.(11'1610)
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