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UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILM <br /> (One page per site) Page L of <br /> TYPE OF.ACTION ❑1.NEW PERMIT [13.RENEWAL PERMIT ❑5.CHANGE OF INFORMATION ❑7.PERMANENTLY CLOSED SITE :00 <br /> (Check one ism ody) 4.AMENDED PPERMIT ((SpppeeEehauBe) X8.TANK REMOVED <br /> 6 <br /> I. FACILITY/SITE INFORMATION- <br /> BUSINESS <br /> NFORMATIONBUSINESS NAME(S.at FACILITY NA1,4117 rDew-Doing Somas An 3. FACILITY <br /> �QW MG.n i'r0 p ID# ' <br /> NEAREST CROSS f-'SS STREET 401. FACILITY OWNER TYPE ❑4.LOCAL AGENCY/DISTRICT' <br /> I. <br /> h, 4e Ln i- r'fe_y' oel+ SA-ree,T [-11.CORPORATION ❑5.COUNTY AGENCY- <br /> BUSINESS Lj 1.GAS STATION 3.FARM Lj 5.COMMERCIAL °� 5,2.INDIVIDUAL ❑6.STATE AGENCY- <br /> TYPE ❑2.DISTRIBUTOR [14.PROCESSOR ❑6.OTHER ❑3.PARTNERSHIP ❑7.FEDERAL AGENCY* <br /> TOTAL NUMBER OF TANKS rvation 405. "If owner of UST is a public agency: cubic of supervisor of division,section or 496. <br /> REMAINING AT SITE o[lips[Lmds7 office which operates the UST. (Chia is the contact penin for the book records.) <br /> ❑Yes �No <br /> } <br /> >.. „` .. II.. PROPERTY OWN" <br /> PROPERTY OWNER NAME 407. PHONE 4e8. <br /> amino ene w a X09- 93 I - 3 5`IZ <br /> MAILING OR STREET ADDRESS °Dr <br /> I-anp <br /> CITY <br /> 4l0. STATE <br /> 411. ZIPCODE 411 <br /> S'-oc,ICa-or\ A <br /> PROPERTY OWNER TYPE LJ 1.CORPORATION 2.INDIVIDUAL U 4.LOCAL AGENCY/DISTRICT LJ6.STATEAGENCY 713. <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY [17.FEDERAL AGENCY <br /> III.T A.NK OWNER LNFORVLITION <br /> TANK OWNER NAME 414. PHONE 415. <br /> SC.,.M2 O L ��U ¢r Owner _ <br /> MAILING OR STREET ADDRESS 416 <br /> CITY 417. 1 STATE 418. ZIP CODE 419. <br /> TANK OWNER TYPE ❑1.CORPORATION ❑2.INDIVIDUAL ❑4.LOCAL AGENCY/OISTRICT ❑6.STATE AGENCY 420. <br /> [:13.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 41- Call(916)323-9669 1f questions arise <br /> V. PETROLEUM:UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ❑1.SELF-INSURED ❑4.SURETY BOND ❑7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM 4M <br /> [12.GUARANTEE ❑5.LETTER OF CREDIT ❑S.STATE FUND&CFO LETTER [199.OTHER, <br /> ❑3.INSURANCE ❑6.EXEMPTION ❑9.STATE FUND&CD <br /> VI.LEGAL NarIFICATION:AND NJAILING ADDRESS <br /> Check one box to mdmas which addrrsi should be used for legal m rficamus and mailing <br /> Legal o f,.aums and melliegs will be sera to the war owns edeas box I or 2 is chaked. ❑ I.FACILITY ;,2. PROPERTY OWNER [13.TANK OWNER 423. <br /> VIL APPLICANT SIGNATURE <br /> CartnfkmtmmIpanify,that the bfformation provided beema b neo and aommue in the bat of my kmwledge. <br /> SIG P ANT_ /1r� DATE ° PHONE °u <br /> N OF APPLICANT(print) 42& TITLE OF APPLICANT <br /> G�riSEo qtr Z k �1e f Q eIj- FOU- ?r-per'-y Qwnel r- <br /> STATE UST FACILITY NUMBER(Agency me ably) 426. 1998 UPGRADE CERTIFICATE NUMBER(Agency ase oNr) 429. <br /> (See Data Element 1,above, <br /> UPCF HwAvre-x(1/99)-I/2 http://www.unidoevorg Rev.MUM <br /> 0 0 <br />