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UN".,afD PROGRAM CONSOLIDATED FORM �\�� PIR 4: <br /> UNDERGROUND STORAGE TANKS C N: <br /> - FACILITY �y1 <br /> (one page per site) I �7 <br /> KA <br /> TYPE OF ACTION I.NEW SITE PERMIT E] 1RENEWAL PERMIT 5.CHANGE OF INFORMATION ).PERMANENTLY CLOSED SITE \ I� IIr�UJT <br /> (Check one item only) ❑ ❑ <br /> ❑ 4.AMENDED PERMIT ryciry change tool use only ❑ B.TANK REMOVED <br /> ❑6.TEMPORARY SITE CLOSURE loo <br /> 1.FACILITY/SITE INFORMATION <br /> BUSINE$$NAME(smcss FACILITY NAME or DBAOamg"lime"N) 3 FACILRY IDp PR IDN <br /> NEARS CROSS STREET I @ �b FACILITY OWNER TYPE <br /> 4p1 ❑4.LOCAL AGENCYXASTRICT• <br /> tor a I.CORPORATION <br /> BUSIN S ❑ I,GASSTATION ❑ 3.FARM ❑ 5.COMMEKCIAL ❑ 2.INDIVIDUAL ❑ 5.COUNTY AGENCY' <br /> TYPE ❑ 6.STATE AGENCY• <br /> ❑ 2.DISTRIBUTOR ❑4.PROCESSOR 6.OTHER 403 ❑ 3.PARTNERSHIP ❑ T.FEDERAL AGENCY- 402 <br /> TOTAL NUMBER OF TANKS Is faeili ly on Indian Reservation or •Ifowwu of UST is a public agency:name ofsupervisor ofdivision,section or office which operates <br /> REMAINING AT SITE Inn lands? the UST(This is the contact person for the lank tmords.) <br /> / 4.10 Yes ($No los <br /> 406II.PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME <br /> I <br /> Oar PHONE <br /> dos <br /> MAILINGORRET s�SL <br /> orl <br /> ew,q <br /> -) v n kr S . 409 <br /> CITY 5 fo C'Kort a6 STATE C eu ZIP CODE <br /> /-t QSLOoZ dtl <br /> PROPERTY OWNER TYPE (� L CORPORATION ❑ 2.INDMDUAL ❑4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY <br /> ❑3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY 413 <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE <br /> 415 <br /> A! ADD Got ora><on 2.00 9111 -g36 <br /> MAILING OR SpTREET ADD,R1ESS ��// / <br /> 6 A7 r 4,,n e/- f f- 416 <br /> CITY STATE <br /> SPCODGr <br /> E 9'SZ0Z 419 <br /> fo c t�i coGig 419 -I J <br /> TANK OWNER TYPE <br /> P!k4.COFP0 ❑ 2.INDIVIDUAL ❑ 4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY 420 <br /> ❑ 3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- Call(916)322-9669 if questions arise 421 <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) I.SELF-INSURED ❑4.SURETY BOND ❑ 7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM <br /> ❑2.GUARANTEE ❑ S.LETTER OF CREDIT ❑ 8.STATE FUND&CFO LETTER ❑99.OTHER <br /> ❑3.INSURANCE ❑ 6.EXEMPTION ❑ 9.STATE FUND&CD 422 <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one box to indicate which address should be used for legal notifications and nailing. <br /> LF CILI ❑2.P R7l'OWNER ❑},TANK OWNER 423 <br /> Legal notifications and mailing will be sent to the tank owner unless box 1 or 2 is checked. <br /> VIt.APPLICANT SI NA <br /> Cmification-I certify that the informs' provided herein is true and actuate to the best of my knowledge. <br /> SIGNATURE OF A DATE <br /> 424 PHONE 423 <br /> IZ //2 0� �ly _ 6C7L-23ov <br /> 4Z6 <br /> NA E OF CANTPrint) TITLE OF APPLI ANT <br /> ,T,-r Vice- Pr4SlG(-/ 422w/�. <br /> STATE UST FACILITY NUMBER(For laal on only) 426 1998 UPGRADE CERTIFICATE NUMBER(For lootlaeonly) 429 <br /> Is 1998 Compliant? <br /> UPCF(1/99 revised) <br />