Laserfiche WebLink
UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page per site) Page_o£_ <br /> TYPE OF ACTION [31.NEW SITE PERMIT [33.RENEWAL PERMIT 5.CHANGE OF INFORMATION ❑ 7.PERMANENTLY CLOSED SITE <br /> (Check one item only) [34.AMENDED PERMIT specify change local use only ❑ 8.TANK REMOVED <br /> ❑67FMPORARY SITE CLOSURE 4011 fy�r} . <br /> I. FACILITY/SITE INFORMATION <br /> BUSINESS NAMEj(S�wFACILITY NAMEor DB -DoingBusiness As) 3 FACILITYID# r1A 101 <br /> NEAI C O ST� ` Oat FACT FACILITY OWNER TYPE 4.LOCAL AGENCYIDISTRICT• k <br /> /(r FU <br /> ❑ L CORPORATION ❑5.COUNTY AG C' <br /> VW <br /> BUSINESS 1.GAS STATION 3,FARM 5, COMMERCIAL P 2.INDIVIDUAL ❑6.STATE AGENCY* <br /> TYPE E32.DISTRIBUTOR ❑4.PROCESSOR❑6. OTHER 403 ❑ 3.PARTNERSHIP ❑7.FEDERAL AGENCY' 402 t <br /> TOTAL NUMBER OF TANKS Is facility on Indian Reservation or `If owner of UST is a public agency:name of supervisor of division,section or office which 4/r <br /> REMAINING AT SITE trtrstlands? operates the UST(This is the contact person for the tank records) ( ! <br /> a(A ❑ Yes tN No 4i15 406 <br /> II. PROPERTY OWNER INFORMATION i�''+ srNs flye#4 A PJe)/I <br /> 407 <br /> PROPERTY OWNER NAME/J ( /+ s '3r�F�� - <br /> �+ h+� j� <br /> l/�`" Y E!1 <br /> MAILING OR STREET ADDRESS l r f 409 <br /> tG Iv Y-�� r <br /> CITY / 410 STATE jJ ,/I 4kl ZIP CODE /�y i / Q 412 <br /> PROPERTY OWNER TYPE 1,CORPORATION 2.INDIVIDUAL Lj 4.LOCAL AGENCY/DISTRICT 6.STATE AGENCY <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY 413 <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME }� ,(�[/J// 414 PHONE 415 <br /> MAILING OR STREET ADDRESS 416 <br /> CITY 427 STATE 419 ZIP CODE 419 <br /> TANK OWNER TYPE El 1.CORPORATION 2.INDIVIDUAL ❑4.LOCAL AGENCY I DISTRICT ❑6.STATE AGENCY 420 <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> W.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY TK HQ 44- Cal! 916 322-9669 if questions arise 421 <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) [It.SELF-INSURED ❑4.SURE'T'Y BOND 7.STATE FUND ❑10.LOCAL GOVT MECHANISM <br /> [12.GUARANTEE [15.LETTER OF CREDIT ❑S.STATE FUND&CFO LETTER ❑ 99.OTHER: <br /> ❑3.INSURANCE ❑6.EXEMPTION ❑9.STATE FUND&CD 422 <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 1 or 2 is checked 1.FACILITY ]2. PROPERTY OWNER 3.TANK OWNER 423 <br /> VII.APPLICANT SIGNATURE <br /> Certification-I certify that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNA VRE OF APPLICANT g DATE 4 HONE 425 <br /> NAME PLICANT(prim 426TITL OF rAPPLICANT <br /> az7 <br /> STATE UST PACILITY NUMBER(For local use only) 429 1999 UPGRADE CERTIFICATE NUMBER(For local use only) 429 <br /> UPCF(1199 revised) 8 Formerly SWRCB Form A <br />