Laserfiche WebLink
UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS ICY <br /> UNDERGROUND STORAGE TANKS - FACILITY S�lB <br /> (One page per site) Page_of <br /> TYPE OF ACTION [11.NEW PERMIT ❑3.RENEWAL PERMIT ❑5.CHANGE OF INFORMATION ❑7.PERMANENTLY CLOSED SITE 400. <br /> (Chackona item only) ❑4.AMENDED PE (Specify change) ®.8!PANK REMOVED <br /> [16.TEMPORARY SITE SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION <br /> BUSINESS <br /> SNNAME(Seme as FACILITY NNA?M�E or DBA-Doing Bmi�As) 3. FACILITY <br /> /vJbAQwA1C O, �-7ui1E�?A1Lf ;JT r� ID#pp - L <br /> NEAREST CROSS STREET Pte, e apt. FA ILIT OWNERTYPE 4.LOCAL AGENCY/DISTRICT• 402. <br /> SAPJ n1 S1. ❑ I.CORPORATION r <br /> UNTY AGENCY•BUSINESS ❑1.GAS STATION ❑3.FARM 5.COMMERCIAL 403 ❑2.INDIVBJUAL�, ATE AGENCYTYPE ❑2.DISTRBUTOR ❑4.PROCESSOR IS>"DuTHER ❑3.PARTNERSHIPDERAL AGENCY <br /> TOTAL NUMBER OF TANKS 404. Is facility on Indian Reservation 405. a If owner of UST is a public agency:an=of supervisor of division,motion or 406. <br /> REMAINING AT SITE or trust Inds? office which opera es the UST. (This u the contact person for the tank records.) <br /> El Yes QI.Ne- G4�� IJ}M ' JF- 7%AL T <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME �-+ 407. PHONE 408 <br /> 5l�7C1 �Tq4 ul t _ AAJrAL, <br /> t!L7 <br /> MAILING OR STREET ADDRESS <br /> �z.z E , W&3bz�4>,�_ <br /> 409. <br /> ST411. ZIP CODE <br /> Y ATE 412,41a. � 95 Zo Z <br /> PROPERTY OWNER TYPE 1.CORPORATION 2.INDIVIDUAL LJ 4.LOCAL AGENCY/DISTRICT 6.STATE AGENCY 413- <br /> ❑3.PARTNERSHIP M4-170UNT'Y AGENCY ❑7.FEDERAL AGENCY <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415 <br /> J Jo- AQwtJ CuKl'r <br /> MAILING OR STREET ADDRESS 1 416, <br /> CITY )QA v T _ • y 417. STATE 41E, ZIP CODE 62�0 ? 419. <br /> L F_SON1 CA <br /> TANK OWNER TYPE ❑1.CORPORATION El 2.INDIVIDUAL ❑4�.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 420. <br /> ❑ r�3.PARTNERSHIP [�rfOUN'TY 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 ❑4.SURETY BOND [17.STATE FUND <br /> ❑10.LOCAL GOVT MECHANISM 422 <br /> 2.GUARANTEE [15.LETTER CREDIT ❑S.STATE FUND&CFO LETTER ❑99.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 sew to the tank owner unless box 1 or 2 is checked [__11.FACILITY L]�/1. PROPERTY OWNER [:13.TANK OWNER 423, <br /> VII.APPLICANT SIGNATURE <br /> Certification: I certify that the information provided herein is we and accurate to the best of my knowledge. <br /> SIGNATURE OF APPLICAN DATE 424 PHONE 425. <br /> ��F1321EL h/L�t►� �'iO �Ur 7 1.041- 4G� ZlV <br /> NAME OF APPLICANT(print) 426. OF APPLICANT {{ 427 <br /> ffLE . <br /> 1p !C <br /> STATE UST FACILITY NUMBER(Agency a se only) 428. 1998 UPGRADE CERTIFICATE NUMBER(Agency me only) 429. <br /> (See Data Element 1,above. <br /> UPCF HwRvre-a(1/99)-112 http:/Iwww.unidocs.org Rev.02/16/00 <br />