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UNIFIED PROGRAM CONSOLIDATED FORM g 9 <br /> TANKS TT a .1 <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (One page per site) Page-Loft �y�27Vr/ <br /> C <br /> TYPE OF ACTION ❑I.NEW PERMIT [33.RENEWAL PERMIT ❑S.CHANGE OF MFORMATION ❑ 400 7.PERMANENTLY CLOSED SI <br /> (Check one item only) ❑4.AMENDED PERMIT (Specify change) S.TANK REMOVED <br /> [16.TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION <br /> BUSINESS NAME(s.as FACILITY NAME or DBA-Doing Bunter As) J. <br /> ISO,aCS 1'0 per* 4 <br /> roaI <� <br /> NEAREST CROSS STREET o1. FACILITY OWNERTYPE Li 4.LOCAL AGENCY/DISTRICT- <br /> 4oz. <br /> qO3 ,5 ®1.CORPORATION E]5.COUNTY AGENCY* <br /> Un' QfSI'l' 4ca. <br /> BUSINESS I. AS STATION 3.FARM 5.COMMERC ❑2.IN ❑6.STATE AGENCY* <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR ❑6.OTHER ❑3.PARTNERSHIP ❑7.FEDERAL AGENCY' <br /> TOTAL NUMBER OF TANKS 40/ Is facility on Indian Reservation 405. •If owner of UST is a public agency:tame of supervisor of divlaioo,section or <� <br /> REMAINING AT SITE or trust lands? office which operates the UST. (Itis is the contact person for the tank records.) <br /> Qh2 El Yes t9No <br /> `II. PROPERTY OWNER INFORMATION. <br /> PROPERTY OWNER NAME 401 PHONE 408. <br /> TA 64 co l}cl�;^ ,411 2 S'S- ZO ZD <br /> 409MAB.INGOR STET ADDRESS „ L <br /> J }jC.U/lA1 �'i <br /> 410. 1 STATE 4It. ZB'CODE / 4¢. <br /> CITY e� <br /> PROPERTY OWNER TYPE I.CORPORATION El 2.INDIVIDUAL U 4.LOCAL AGENCY/DISTRICT Ljo.M113AGENCY <br /> 4u. <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY. <br /> IH:.TANK OWNER INFORMATION <br /> 414NE as. <br /> TANK OWNER NAME _ . PO _ <br /> Snlo�rQ co �1o1ZOZ® <br /> 416. <br /> MAB.ING OR STREET ADDRESS <br /> CITY 417. ,t STA r AM1/ng. ZIP CODE r ,r� 419. <br /> TANK OWNER TYPE JA I.CORPORATION ❑2.INDIVIDUAL 4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 4zo. <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE.FEE ACCOUNT NUMBER. <br /> TY TK H 44 Call 916 322-9669 if questions arise 42L <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ❑1.SELF-INSURED ❑4.SURETY BOFID [17.STATE FUND [110.LOCAL GOVT MECHANISM 411. <br /> ❑3.GUARANTEE <br /> UA INSURANCE 5.LEITER OF❑b .EXEMPT ON CREDIT O 9.STATE FUND&CD LETTER X".OTHER ALJ07'\-Qi <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check ane boz la indice[c which address should be used Cor legal notifications and mailing 423 <br /> Legal notifications and mailings will be sent to the tank owner unless box I or 2 is checked. ❑ I FACILITY 14 2. PROPERTY OWNER [13.TANK OWNER <br /> VIE APPLICANT SIGNATURE <br /> Certification: I certify,that the information provided herein is hue and accurate to the best of my knowledge. 434. PHONE 2 41'5' <br /> SI NATUBEO P CANT DATE <br /> F-a-(bL't I 09) SYS-93/a <br /> WE OF PAR 1YICANT(Print) <br /> azs. TITLE OF APPLIC Ck 427. <br /> STATEUST FACII.TTY NUMBER(Agency ase only) 428. 1998 UPGRADE CERTIFICATE NUMBER(Agency we only) 429' <br /> STATE <br /> (See Data Element 1,above. <br /> UPCF Hwfwrca(1/99)-IQ ht(p://wm,.unidocs.org Rev.02/16/00 <br />