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UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> 'v (one page per site) <br /> Page _L of <br /> TYPE OF ACTION r 1.NEW SITE PERMIT r 3.RENEWAL PERMIT CHANGE OF INFORMATION(Specifychange- r 7.PERMANENTLY CLOSED SITE <br /> (Check one item only) 4.AMENDED PERMIT local use only) r 8.TANK REMOVED 400 <br /> r <br /> F 6.TEMPORARY SITE CLOSURE <br /> C (i 1"5 ® I.FACILITY I SITE INFORMATION <br /> BUSINESS NAME(Same as FACiLI1VNME or -Doi Business As) 3 FACILITY ID N <br /> _51fe, i I Sit 1 00/111-619 <br /> NEARESTryr,s�CROSS STREET 401 �+ FACILITY OWNER TYPE r 4. LOCAL AGENCYIDISTRICT- <br /> 1 C,024A.J fir 11. CORPORATION r 5. COUNTY AGENCY* <br /> BUSINESS TYPE 1 GAS STATION r 3.FARM r 5.COMMERCIAL >46 INDIVIDUAL <br /> F 6. STATE AGENCY' <br /> r 2.DISTRIBUTOR r 4.PROCESSOR r 6.OTHER r 3. PARTNERSHIP r 7. FEDERAL AGENCY' 402 <br /> 403 <br /> TOTAL NUMBER OF TANKS Is facility on Indian Reservation or 'If owner of UST is a public agencyname of supervisor of <br /> REMAINING AT SITE W sllantla7 division.motion or office ce which operates the US <br /> (This is the contact person for the tank records.) <br /> 404 3 r Vas XNo 405 406 <br /> II.PROPERTY OWNER INFORMATION <br /> PROPERTY OWN AM� 407 rr /S `�;b 0339-�`fd I <br /> MAILING OR STREET ADDRESS 409 <br /> i,,51)"S E. <br /> CITY 410TATE 411 ZIPCODE 412 <br /> {�� c� '�1sa0a <br /> PROPER]Y OWNER TYPE 2. INDNIDUAL r 4. LOCAL AGENCY I DISTRICT r 6. STATE AGENCY 413 <br /> r 1. CORPORATION r 3. PARTNERSHIP r 5. COUNTY AGENCY r Z FEDERALAGENCY <br /> III.TANK OWNER INFORMATION <br /> TANK PHONE <br /> `OWNERNAME 41Chef FEry`i S 6a09�133 f- YLI/ <br /> MAILING OR STREET ADDRESS 41 <br /> cSCt o aL cL <br /> 42yll'z <br /> CITY 417 STATE 418 ZIP CODE 419 <br /> Pea, )" c� �fi 9 Baa <br /> TANK OWNER TYPE IND NIDUAL r 4. LOCALAGENCY/DISTRICT r 6. STATEAGENCY 420 <br /> r CORPORATION r 3 PARTNERSHIP r 5 COUNTYAGENCY r 7. FEDERALAGENCY <br /> TY(TK)HQ 4 4 - Call(916)322-9669 if questions arise 421 <br /> anualaff IW <br /> INDICATE METHOD(S) r 1. SELF-INSURED r 4. SURETYBOND r 7. STATEFUND r 10. LOCAL GOV=T MECHANISM <br /> F 2. GUARANTEE r 5. LETTER OF CREDIT r B STATE FUND 8 CFO LETTER YC99. OTHER: 22 !9:�J <br /> r 3. INSURANCE r 6. EXEMPTION r 9. STATE FUND 8 CD 422 <br /> Check one box to indicate which address should be used for legal notifications an=. I 1. FACILITY 2. PROPERTY OWNER r 3. TANK OWNER 423 <br /> Laos notifications and mailin s will by sent to the tan ..nw unI...box 1 or <br /> Certhcalion. I certify that the information provided herein is two and accurate to the beet of my Wwwledge. <br /> SIGNATURE OF APPLICANT DATE 424 1 PHONE 425 <br /> NAME OF APPLICANT(pnith 426 TITLE OF APPLICANT 427 <br /> STATE UST FACILITY NUMBER(Forlocal use only) 428 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 <br /> at"o %fie auk 3 uS1"s 9-la -Do <br /> UPCF(1/99 r/99 r it / o Formerly SWRCB FornT1C <br /> l g�� p�j t)'" od r a 57K <br /> G�� PRD 5.11 5 Cb 413/45 ' <br />