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4 -- <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page per site) <br /> EE I - <br /> - Papa _ o <br /> TYPE OF ACTION ]- 1.NEW SITE PERMIT r 3.RENEWAL PERMIT F 5.CHANGE OF INFORMATION(Sp fy change- r ].PERMANENTLY CLOSED SITE <br /> (Chad one item only) r 4.AMENDED PERMIT fOCal ose,onfy) r B.TANK REMOVED 100 <br /> F 6.TEMPORARY SITE CLOSURE <br /> I.FACILITY I SITE INFORMATION <br /> BUSINESS NAME(Same as FACILITY NAME a OBA-Doing Business As) 3 FACILITY 10 a <br /> I} a LLL DgAY FW4LOCAL AGENCY/DISTRICT' <br /> E �SS STRET <br /> NER TYIE <br /> r-1. CORPORATION <br /> r S. COUNTY AGENCY' <br /> BUSINESS TYPE r 1 GAS STATION r 3.FARM r S.COMMERCIAL r 2. INDIVIDUAL r 6. STATE AGENCY' <br /> F 2.DISTRIBUTOR r 4.PROCESSOR r &OTHER r 3. PARTNERSHIP r ]. FEDERAL AGENCY' 102 <br /> 403 <br /> TOTAL NUMBER OF TANK$ Is/acility on(Mian Reservation a 'l/owner of UST is a WM1lic agency:name of eupemism of <br /> REMAININGATSITE lruallarWs? divialdn.sectwn or office whi operates the UST. <br /> (This is the contact person for the lank records.) <br /> 40a 3 r Yea r o' 105 406 <br /> II.PROPERTY OWNER INFORMATION <br /> PROPERTY ONMER NAME 407 PHONE 406 <br /> Ur tFi e�5� 2 � � T 339 -QDL38 <br /> MAILING OR STREET ADDRESS 409 <br /> TATE,.. 411 ZIP CODE 412 <br /> C. <br /> CIN 410 n.]Y ( <br /> ic `S ZS <br /> 2 <br /> PROPERTY OWNER TYPE r 2. INDIVIDUAL r 4. LOCAL AGENCY/DISTRICT r 6. STATE AGENCY 913 <br /> 1. CORPORATION r 3. PARTNERSHIP r 5. COUNTYAGENCY F 7 FEDERALAGENCY <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> sc Z4 2 �-�-� 339 - x]23 <br /> MAILING OR STREET ADDRESS 416 <br /> U to l cx XyL S�t2 o t�Ern IZ <br /> CITY 917 STATE 418 21PC D 419 <br /> cy✓, I9 SZS`Ej <br /> TANK OVMER TYPE1 r 2. INDIVIDUAL r 4. LOCAL AGENCY/DISTRICT r 6. STATE AGENCY 420 <br /> CORPORATION r 3. PARTNERSHIP r 5. COUNTYAGENCY r ]. FEDERAL AGENCY <br /> TY(TK)HO 1 4 4 Call(916)322-9669 if questions arise 421 <br /> INDICATE METHODS) r 1. SELF-INSURED r 4. SURETY BOND - r 1. STATE FUND r 10. LOCAL GOV=T MECHANISM <br /> r 2. GUARANTEE r 5. LETTER OF CREDIT r S. STATE FUND E CFO LETTER r 99. OTHER: <br /> F 3. INSURANCE r 6. EXEMPTION r 9. STATE FUND&CO 422 <br /> Chad one tax to uMcate which address should fie used for legal notifications and mailing. , FACILITY r 2. PROPERTY OWNER r 3. TANK OWNER 423 <br /> ratdwations antl mailin swill by lentto the tank.2C pleas las 1 or 2 is checked. <br /> Certif"tim: 1 urt4y that pie n/ormalion provided M1erein 4 true aM acarale to tM1e Dea10l my knowbdpe. o- !' <br /> SIGNATURE OF APPLI T DATE yZ ca3 424 1 PH 5 q/3_7CZJ 425 <br /> NAME OF APPLICAN (print) 426 TITLE OF APPLICANT 427 <br /> 1,4w¢E,L CC wL I�r L <br /> STATE UST FACILITY NUMBER(For locaf use only) 426 1998 UPGRADE CERTIFICATE NUMBER(For local so only) 429 <br /> UPCF(1199 revised) 5 � ��Y/(] I Formerly SWRCB Form A <br />