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UNIFIED PROGRAM CONSOLIDATED FORM CO ' I TANKSUNDERGROUND STORAGE TANKS - FACILITY t�•� (C t(One page per site) Page_of TYPE OF ACTION ❑ L NEW PERMIT ❑3.RENEWAL PERMIT J"`CHANGE OF INFORMATION ❑7.PERMANENTLY CLOSED SITE 400. (Check one item only) ❑4.AMENDED PERMIT (Specify) [19.TANK REMOVED ❑6.TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3. FACILITY NEAREST Cc) v-- ET 55 O 1 A, aol. FA 1.CORPORATIONILITY OWNER E]5.COCAL STRICT* aoz. COUNTY AGENCY* - BUSINESS GAS STATION) 3.FARM v E]5.COMMERCIAL 403 �2.INDIVIDUAL ❑6.STATE AGENCY* TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR [16.OTHER 3.PARTNERSHIP ❑7.FEDERAL AGENCY* TOTAL NUMBER OF TANKS 404. Is facility on Indian Reservation 405. f owner of UST is a public agency: name of supervisor of division,section or 406. REMAINING AT SITE or trust lands? office which operates the UST. (This is the contact person for the tank records.) ❑Yes No H. PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407. PHONE 409. SRA 1 sN T L- •zoo 8 3 --7 MAILING OR STREET ADDRESS 409 CITYC alo. STA � 411. ZIP CODE � az. 9 PROPERTY OWNER TYPE 1.CORPORATION Lj 2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT 06.STATEAGENCY 413. [f3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY III.TANK OWNER INFORMATION TANK OWNER NAME 414. 1 PHONE 415. s N coq, g -3 -7 7 MAILING OR STREET ADDRESS 416. 7 PA--Tsv r� CITY 417STATE 419. ZIP CODE 419. C- c 5 3 TANK OWNER TYPE I.CORPORATION ❑2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STA AGENCY 420. 3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY TK HQ 44- 1 1 1 1 1 1 1 Call(916)322-9669 ifquestions arise 421 V.PETROLEUM UST FINANCIAL RESPONSIBILITY INDICATE METHOD(s) ❑I.SELF-INSURED ❑4.SURETY BOND ❑7.STATE FUND ❑ 10.LOCAL GOV'T MECHANISM 412 [12.GUARANTEE ❑5.LETTER OF CREDIT ❑9.STATE FUND&CFO LETTER ❑99.OTHER: ❑3.INSURANCE ❑6.EXEMPTION [19.STATE FUND&CD VI.LEGAL NOTIFICATION AND MAILING ADDRESS Check one box to indicate which address should be used for legal notifications and mailing. Legal notifications and mailings will be sent to the tank owner unless box I or 2 is checked. ❑ 1.FACILITY *2. PROPERTY OWNER [13.TANK OWNER 423 VII.APPLICANT SIGNATURE Certification: 1 certify that the information provided herein is true and accurate to the best of my knowledge. SIGNATURE OF APPLICANT--? DATE 424. PHONE 425. NAME OF APPLICANT(print) 426. TITLE OF APPLICANT 427 STATE UST FACILITY NUMBER(Agency use only) 428. 1998 UPGRADE CERTIFICATE NUMBER(Agency use only) 429 (See Data Element 1,above. UPCF Hwfwrc-a(1/99)-1/2 http://www.unidocs.org Rev.02/16/00