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e UNIFIED PROGRAM CONSOLIDATED FORM �j 9 TANKS VT 2 UNDERGROUND STORAGE TANKS - FACILITY (One page per site) Page-LOf C TYPE OF ACTION ❑1.NEW PERMIT [13.RENEWAL PERMIT ❑5.CHANGE OF INFORMATION ❑7,PERMANENTLY CLOSED SI .�,400. (Check are item only) [14.AMENDED PERMIT (Specify change) S.TANK REMOVED ❑6.TEMPORARY SITE CLOSURE L J 7 I. FACILITY/SITE INFORMATION 60 7- oS�AA BUSINESS NAME(samaw FACILDYNA or DBA-Doing11sinev As) 3. FACILITY "tl lL Ts at`Sro r* ID"F 5 NEAREST CROSS STREE m. FACE, YOWNE TYPE Ll 4.LOCAL AGENCY/DISTRICT* 402. Un- 4 .5 1.CORPORATION E35.COUNTY AGENCY* BUSINESS 1. AS STATION ❑3.FARM 5.COMMERCIAL 403. ❑2.INDIVIDUAL ❑6.STATE AGENCY* TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR ❑6.OTHER ❑3.PARTNERSHIP ❑7.FEDERAL AGENCY* TOTAL NUMBER OF TANKS 494 Is facility on Indian Reservation 405. -If owner of UST is a public agency:name of supervisor of division,section or 406. REMAINING AT SITE or trust lands? office which operates the UST. (This is the contact person for the tank records. ' QY\e- ❑Yes CaNo II. PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 001 PHONE acs. TellaNg o Fkagj\ zozo MAILING OR STREET ADDRESS 80 Wam,*1�/"L al [d , 7 / ^i 40v. CITY J 410' 1 S',T�AA*'TTE-' l. 4H. ZIP CODE 4I2. CA- 95-2 to PROPERTY OWNER TYPE I.CORPORATION 2.INDIVIDUAL 4.LOCAL AGENCY/DISTRICT 6.STATE AGENCY 413. ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY III..TANK OWNER INFORMATION TANK OWNER NAME 414. P ONE 415. Tn\anrn� Pia }�o�cQ n a3) -03,.5-'ZOZO MAILING OR STREET ADDRESS e / p� 416' 5,380 u�kd CITY 7" � 417. STATE (, 41s. ZIP CODE S Z/0 419 TANK OWNER TYPE 1.CORPORATION ❑2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT 6.STATE AGENCY 420. ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑T FEDERAL AGENCY IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY TK)HQ 44- 1 1 1 1 1 1 1 Call 916 322-9669 if questions arise 421. V.PETROLEUM UST FINANCIAL RESPONSIBILITY INDICATE METHOD(s) ❑1.SELF-INSURED [14.SURETY BOND [17.STATE FUND [110.LOCAL Gov r MECHANISM au ❑2.GUARANTEE ❑5.LETTER OF CREDIT ❑8.STATE FUND&CFO LETTER .$99.OTHER: yes-y R. [13.INSURANCE ❑6.EXEMPTION ❑9.STATE FUND&CD VI.LEGAL NOTIFICATION AND MAILING ADDRESS Check one box to indicate which address should be used for legal notifications and marling. Legal notifications and mailings will be sent to the tank owner unless box I or 2 is checked. ❑ 1.FACILITY 0 2. PROPERTY OWNER ❑3.TANK OWNER 413, VII.APPLICANT SIGNATURE Certification: I certify that the information provided herein is"a and accurate to the best ofmy knowledge. SI NATURE OPP CANT DATE 424. 1 PHONE 4z5. zoy) SYo- I'm faOF A P Ip (.CANT(print) 416. TITLE OF APPLICANT 4n. TrIsG�_c`�-,1l/lM1�oY (F3,�_�,�__a'(/") l/41' tet, STATE UST FACILITY NUMBER(Agency wo only) 428. 1998 UPGRADE CERTIFICATE NUMBER(Agency ae only) 429_ (See Data Element 1,above. UPCF Hwfwrc-a(1/99)-1/2 http://www,unidom.org Rev.02/16/00