Laserfiche WebLink
UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page per site) Page_of <br /> TYPE OF ACTION ❑ 1.NEW SITE PERMIT ❑3.RENEWAL PERMrr .CHANGE OF INFORMATION ❑ 7.PERMANENTLY CLOSED SITE <br /> (Check one item only) ❑4.AMENDED PERMIT specify change local use only ❑ 8.TANK REMOVED <br /> ❑67EMPORARY SITE CLOSURE 400 <br /> I. FACILITY/SITE INFORMATION <br /> BUSINESS NA E(Same as FACILITY NAME or DBA-Doing Business As) 3 FACILITY ID# <br /> L Y 1 <br /> NEAREST CROSS gSTREET 401 FACILITY OWNER" 4.LOCAL AGENCY/DISTRICT' <br /> ��v`Q_ S ❑ 1.CORPORATION ❑5.COUNTY AGENCY' <br /> BUSINESS qL1.GAS STATION 3.FARM C1 5. COMMERCIAL -2.INDIVIDUAL ❑6.STATE AGENCY' <br /> TYPE Lj 2.DISTRIBUTOR [14.PROCESSOR[16. OTHER 403 3.PARTNERSHIP ❑7.FEDERAL AGENCY* 402 <br /> TOTAL NUMBER OF TANKS Is facility on Indian Reservation or *Ifowner of UST is a public agency:name of supervisor of division,section or office which <br /> REMAINING AT SITE trustlands? operates the UST 01is is the contact person for the tank records.) <br /> 4o4 ❑ Yes No 405 1 406 <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY rR NAME C 408 <br /> MAILING OR ET ADD S$ � aov <br /> CITY 410 STATE 411 ZIP CODE a12 <br /> _vvc� Lin <br /> PROPERTY OWNER TYPE 1.CORPORATION INDIVIDUAL 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-- � � � � � 414 HONE <br /> MAILING TREj�� 2_Qq ) <br /> DRESS •X L �� 416 <br /> 7 <br /> anST als ZIP COD 4I9 <br /> SANK OWNER TYPF, 1\ ❑ 1.CORPO TION INDIVIDUAL ❑4.LOCAL AGENCY!DISTRICT Lj 6.STATE AGENCY am <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY TK HQ 44- Call 916 322-9669 if questions arise 421 <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) [11.SELF-INSURED ❑4.SURETY BOND W7.STATE FUND ❑10.LOCAL GOVT MECHANISM <br /> [12.GUARANTEE ❑5.LETTER OF CREDIT ❑8.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 /> Ce ' anon certify that the information provided herein is true and accurate to the best of my knowledge. <br /> S NATU OF APPLICANT- Vcd DATE /' 424 PHONE 425 <br /> J, � ` <br /> NAMETOF APPLIC T,(print) l 426 TITLE OF AP LICANT 427 <br /> STATE UST IIACILITY NUMBER(For local use only) 429 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 <br /> UPCF(1/99 revised) 8 Formerly SWRCB Form A <br />