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r a <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page per site) <br /> Page - of _ <br /> TYPE OF ACTION 1.NEW SITE PERMIT r 3.RENEWAL PERMIT r 5.CHANGE OF INFORMATION(Specify Mange- r 7.PERMANENTLY CLOSED SITE <br /> ore <br /> (Check citem only) r 4.AMENDED PERMIT Axel use only) r 6.TANK REMOVED 400 <br /> r e.TEMPORARY SITE CLOSURE <br /> I.FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Some as FACILITY NAME or DBA-Deep Business As) 3 FACILITY ID# 1 �I <br /> kul Ctc co <br /> NWT CROSS ST EET 401 CILITY OWNERTYPE r 4. LOCAL AGENCYIDISTRICT• <br /> (, 1. CORPORATION DEC 14 2000 r 5. COUNTYAGENCY' <br /> BUSINESS TYPE VI.GAS STATION r 3.FARM r 5.COMMERCIAL r 2. INDIVIDUAL <br /> r 2.DISTRIBUTOR r 4.PROCESSOR r 6.OTHER r 3. PARTNERSHIe r r e. STATE AGENCY' <br /> LNVIRONNIENT I IEALT r 7. FEDERAL AGENCY' 402 <br /> 103 <br /> TOTAL NUMBER OF TANKS Is facility on Indian Reservation or •a owner of UST a a public agency f <br /> REMAINING AT SITE trusliaMsl division,section or office which operates the UST. <br /> (This a the mmem permn for the tank records.) <br /> 404 ryes VN. 405 406 <br /> II.PROPERTY OWNER INFORMATION <br /> PROPERTY OWTIER NAME PHONE 406 <br /> L Inca/ P10A'P <br /> �M LING ORSTREET DRESS 409 <br /> / C� ✓ <br /> CITY 410 STATE 411 21P CODE 412. <br /> PROPERTY OWNER TYPE r 2. INDNIDUAL r 4. LOCAL AGENCY/DISTRICT r S. STATEAGENCY 413 <br /> 9/1. CORPORATION r 3. PARTNERSHIP r S. COUNTYAGENCY r 7. FEDERALAGENCY <br /> III.TANK OWNER INFORMATION ' <br /> TANK OWNER NAME 414 PHONE 415 <br /> YVAII C_ r„rE 2 LL (_ <br /> MAILING OR STREET ADDRESS 416 <br /> ;42's Ac)>`t� v <br /> CITY 411 STATE 41& IPC DE 419 <br /> � ac k.' c N C <br /> TANK OWNER TYPE r 2. INDIVIDUAL r 4. LOCAL AGENCY/DISTRICT r 6. STATE AGENCY 420 <br /> V6. CORPORATION r 3. PARTNERSHIP r 5. COUNTYAGENCY r 7. FEDERALAGENCY <br /> TY(TK)HQ 1 4 4 Call(916)322-9669 if questions arise 421 <br /> INDICATE METHODS) r 1. SELF-INSURED r 4. SURETY BOND w 7. STATE FUND r 10. LOCAL GOV=T MECHANISM <br /> r 2. GUARANTEE r 5. LETTER OF CREDIT r & STATE FUND&CFO LETTER r 99. OTHER: <br /> r 3. INSURANCE r 6. EXEMPTION r 9. STATE FUND&CO 422 <br /> _ \1 F!•ALb(QTIFIf TInN Awn M&II Hun AnnppgC <br /> I rrmrk me�w Ivgidiwte whits addroM MDe used for legal nolirxationa end mellirp. r FACILITY r 2. PROPERTY OWNER r 3. TANKMINER 423 <br /> Le al nolifrwlion,and mailin s will be sent b lank owner b boa 1 2 cracked <br /> 1 <br /> Cenincafron' I cenNy that the inf rmal vided herein a W s and accurate to the best of my knowledge. <br /> SIGNtTV,VOF AFPLI T `�.,r DATE 424 PHONE 4Z <br /> NAM O APL A (pin T/4a 64 426 TITLE OF APPLICANT 427 <br /> STATE UST FACILITY NUMBER(FOr/ocal use only) 426 1990 UPGRADE CERTIFICATE NUMBER(For Acal use only) 429 <br /> UPCF(1/99 revised) 5 Formerly SWRCB Form A <br />