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UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (One page per site) Page-of- <br /> TYPE <br /> age_of_TYPE OF ACTION 1.NEW PERMIT [13.RENEWAL PERMIT [15.CHANGE OF INFORMATION [17.PERMANENTLY CLOSED SITE 400_ <br /> (Check oro item only) ❑4.AMENDED PERMIT (Specify change) ❑8.TANK REMOVED <br /> ❑6.TEMPORARY SITE CLOSURE <br /> I. FACILTTY/SITE INFORMATION <br /> BUSINESS NAME(Samc as FACILITY NAME., <br /> DBA-Doing Baamm As) 3. FACIL <br /> TfY <br /> TrIra LNtJUJY 0 � I. <br /> NEAREST CROSS ST T 401. FACILITY OWNER TYPE ❑4.LOCAL AGENCY/DISTRICT' 402. <br /> M..far -. 7„eq�[L�Na ❑ 1.CORPORATION El5.COUNTY AGENCY' <br /> BUSINESS LJQ.GAS STATION Ll 3.FARM 0 S.COMMERCIAL 03 X2.INDIVIDUAL ❑6.STATE AGENCY' <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR [16.OTHER ❑3.PARTNERSHIP ❑7.FEDERAL AGENCY' <br /> TOTAL NUMBER OF TANKS 404. Is facility on Indian Reservation 405. •If owner of UST is a public agency:name of supervisor of division,section or 4% <br /> REMAINING AT SITE or trust hunts? office which operates the UST. (This a the contact person for the tank records.) <br /> ❑Yes IDI No <br /> R. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME <br /> /� / ///� ._,, ,( 41* 1 PHONE q9 <br /> MAILING OR STREET ADDRESS W �L7 V 409 <br /> Ll3 4 . n1a..t;� cS+- <br /> CRY 41a. 1 STATE �� 411. ZIB CODE SO 4¢. <br /> ton GaAs <br /> PROPERTY OWNER TYPE LILCORPORATION U2.1NDIVIVIJAI, Ll 4.LOCAL AGENCY/DISTRICT El 6.STATE AGENCY 413_ <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME dla. 1 PHONE/' �C19 . 11q r- els. <br /> MAILING OR STREET ADDRESS `1 1 �fl 416. <br /> Ll a E. � . <br /> CITY 417. 1 STATE �4 419. 1 ZIP CODE _ -� 419. <br /> TANK OWNER TYPE ❑ L CORPORATION ❑2.INDIVIDUAL Lj 4.LOCAL AGENCY/DISTRICT [16.STATE AGENCY 420. <br /> ❑3.PARTNERSHIP El 5.COUNTY AGENCY [17.FEDERAL AGENCY <br /> W.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY TK HO 44- Call 916 322-9669 if questions arise 421. <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ❑1.SELF-INSURED ❑4.SURETY BOND [17.STATE FUND ❑10.LOCAL GOVT MECHANISM 422 <br /> [12.GUARANTEE ❑5.LETTER OF CREDIT ❑8.STATE FUND&CFO LETTER ❑99.OTHER: <br /> ❑3.INSURANCE ❑6.EXEMPTION ❑9.STATE FUND&CD <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check oro box to indicate which address should be used for legal notifications and roiling. <br /> Legal notifications and mailings will be sent to the tank owner unless box I or 2 is checked ❑ 1.FACILITY [12. PROPERTY OWNER ❑3.TANK OWNER 423. <br /> VII.APPLICANT SIGNATURE <br /> Certification: I certify that the information provided herein is true and accurate o the best of my knowledge. <br /> SIG F DATE azo. ONEass. <br /> 8 a /va �1os 9ya St�8(0- <br /> E OF APPLICANT(print) 426. TITLE OF APPLICANT 4$7' <br /> STATE UST FACILITY NUMBER(Agency use only) e 428. 1998 UPGRADE CERTIFICATE NUMBER(Agency ore only) 429. <br /> (See Data Element 1,above. <br /> UPCF Hwfwrc-a(1/99)-1/2 http://www.unidoes.org Rev.02/16/00 <br />