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D <br /> 0 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> pill,TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (One page per site) Page_of <br /> TYPE OF ACTION ❑ 1.NEW PERMIT []3.RENEWAL PERMIT 5.CHANGE OF INFORMATION 400. <br /> (Check one item only} ❑4.AMENDED PERMIT (Specify c ange) ❑7•PERMANENTLY CLOSED SITE <br /> ❑6.TEMPORARY SITE CLOSURE ❑S.TANK REMOVED <br /> I. FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Same FACILITY NANI or DBA-Doing Business As) 3. FACILITY <br /> �4l �r- ��Vra,'\ IDI! tl�ARE$T CROS T ET 4011 FACILITY OWNER TYPE Q 4.LOCAL AGENCY/DIS�Z02 <br /> II G`^ Q 1.CORPORATION ❑5.COUNTY AGENCY* <br /> BUSINESS,L1.GAS STATION ❑3.FARM ❑5.COMMERCIAL 403. 92.INDIVIDUAL ❑6.STATE AGENCY* <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR ❑6.OTHER [-1.3.PARTNERSHIP <br /> ❑7.FEDERAL AGENCY* <br /> TOTAL NUMBER OF TANKS 4114 Is facility on Indian Reservation 405 *If owner of UST is a public agency: name o€supervisor of division, section or 406 <br /> REMAINING AT SITE or trust lands? office which operates the UST. (This is the contact person for the tank records.) <br /> El Yes XNo <br /> Il. PROPERTY OWNER INFORMATION <br /> PRO�P^S YOWNER NAME 407. PHONE <br /> J H-QA^S,/bbid � � 409. <br /> MAILING OR <br /> STREE ADDRESS � 2 - S <br /> 14(3 _ 409. <br /> CITY 410. <br /> -J , STATE 411. ZIP CODE <br /> � �.{` ���� ata. <br /> PROPERTY OWNER TYPE �]�-CORPORATION &,2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6 SSTATE AGENCY 4u. <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME c I t �� p f <br /> S�}�tN•Jv ��1� T 'q", 414. PHOIto `Cl 415. <br /> MAILING{OR STREET AD RESS '+f ` �Z <br /> 14 V 1.� �� -'IJ' 416. <br /> CITY ++rr 417 STATE ala. ZIP CODE <br /> V�AA,-Q C� �3 0 419. <br /> TANK OWNER TYPE ❑I.CORPORATION {'�, INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT <br /> ❑6.STATE AGENCY 42© <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 ttestions arise <br /> 4zi <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ❑1.SELF-INSURED [14.SURETY BOND ❑7.STATE FUND <br /> ❑2.GUARANTEE Q 5,LETTER OF CREDIT ❑S.STATE FUND&CFO LETTER ❑ [0.LOCAL GOVT MECHANISM 4„ <br /> El 3.INSURANCE El 6.EXEMPTION El 9,STATE FUND&CD El 49.OTHER: <br /> VI. LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one box to indicate which address should be used for legal notifications and mailing, <br /> Legal notifications and mailings will be sent to the tank owner unless box I or 2 is checked. <br /> ❑ i.FACILITY ❑2. PROPERTY OWNER ❑3.TANK OWNER 423. <br /> VII.APPLICANT SIGNATURE <br /> Certifica' n: I certify that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGN TURF OF APPLIC T DATE 424. PHONE 425 <br /> s <br /> NAME F APPLICANT(print) 426. TITLE OF APPLICANT <br /> 427 <br /> STATE UST FACILITY NUMBER(Agency use only) 428 1999 UPGRADE CERTIFICATE NUMBER(Agency use only) 429 <br /> (See Data Element 1,above, <br /> UPCF Hwfwre-a(1/99)-1/2 http://wAw.unidGcs.org <br /> Rev.02/16/00 <br />