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I � � I �GIQ1 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS -FACILITY 8�/v <br /> (One page per site) Page_of_ <br /> TYPE OF ACTION ❑1.NEW PERMIT [13.RENEWAL PERMIT ❑5.CHANGE OF INFORMATION S� 46a. <br /> (Cheek one dem onl ) ❑7.PERMANENTLY C ED STfE <br /> Y ❑4.AMENDED PERMIT CLOSURE change) ®.8!1"ANK REMOVED I I <br /> ❑6.TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION S�l <br /> BUSINESS NAME(Same a FACILDT NAME or DBA-Doing Bminew As) 3. FACILITY <br /> AW JbA`QW Al Ce• 4�00bZ1uP-t AWT IDaPD <br /> NEAREST CROSS STREET _ 9 Bot. FA B. OWNER TYPE 4.LOCAL AGENCY TRICT` 402. <br /> 5�2V I N 7S; <br /> . <br /> [11.CORPORATION 0;&-COUNTY AGENCY` <br /> BUSINESS 1.GAS STATION 3.FARM 5.COMMERCIAL 403. <br /> TYPE ❑2.DISTRIBUTOR [14.PROCESSOR ,� � ❑2.INDIVIDUAL 1--]6.STATE AGENCY` <br /> ly�n.ETHER ❑3.PARTNERSHIP ❑7.FEDERAL AGENCY` <br /> TOTAL NUMBER OF TANKS 4K Is facility on Indian Reservation 405. a If owner of UST s a pubic agency:Dome.f supervisor of division,sectio.or 406. <br /> REMAINING AT SITE or trust lands? office whichopen the UST. (This is the contact person for the tank records.) <br /> ❑Yes MN&- 64&7 LAA - ¢ 17ALfn.T <br /> ^7� 11. PROPERTY OWNER INFORMATION c <br /> PROP5ArJOWNERPHONE <br /> V Qa IAI7) GLW-r - CArrAL ezz `-i!/- -Z)p I 4os. <br /> MAILING OR STREET ADDRESS <br /> 22vZ E . u9c�cqz,4>9Ie,,_ <br /> CITY r STATE 411. <br /> aro. ZIP CODE 412. <br /> S-1 OGJL/OIIJ 9S Zp Z <br /> PROPERTY OWNER TYPE 1.CORPORATIONEl 2.INDIVIDUAL El 4.LOCAL <br /> ..,.AGENCY/DISTRICT 6.STATE AGENCY 413. <br /> [13.PARTNERSHIP Mh-tOlUNPY AGENCY [17.FEDERAL AGENCY <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME //�+ 414. PHONE 415. <br /> D lel N l__OIAXI_r - Aoed - I ff <br /> MAILING OR STREET ADDRESS 14t6 <br /> E. We E <br /> CITY 412. 1 STATE 418. ZIP CODE 419, <br /> TANK OWNER TYPE ❑1.CORPORATION ❑2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT LJ6.STATEAGENCY 420. <br /> ❑3.PARTNERSHIP OWIrOUNTY AGENCY [17.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY TK HQ 44- 1 1 1 1 1 1 1 Call 916 322-9669 if questions arise 421. <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ❑1.SELF-INSURED [14.SURETY BOND ❑7.STATE FUND [110.LOCAL GOVT MECHANISM 422 <br /> Q2.GUARANTEE [IS.LETTER OF CREDIT ❑8.STATE FUND&CFO LEITER [199.OTHER: <br /> 3.INSURANCE ❑6.EXEMPTION ❑9.STATE FUND&CD <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 m 2 is checked. ❑ 1.FACILITY M4PROPERTY OWNER ❑3.TANK OWNER 423. <br /> VII.APPLICANT SIGNATURE <br /> Certification: I certify thin the information provided herein is true and accurate to the best ofmy knowledge. <br /> SIGNATURE OF APPLICAN DATE 424 PHONE 425. <br /> 6A13RaEL ftJ 1+►L - 6-7 <br /> NAME OF APPLICANT(print) 4z6. 1TLE OF APPLICANT 422. <br /> STATE UST FACILITY NUMBER(Agmy..nly) 428 1998 UPGRADE CERTIBICA NUMBER(Agency use only) 4z9. <br /> (See Data Element 1,above. <br /> UPCF Hwfwre-a(1/99)-1/2 hftp://www.uniducs.org Rev.02/16/00 <br />