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AdNk <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (One page per site) Page_of / <br /> TYPE OF ACTION ❑I.NEW PERMIT ❑3.RENEWAL PERMIT 5.CHANGE OF INFORMATION 400• <br /> (Check one item only) ❑4.AMENDED PERMIT (Specify e ❑7.PERMANENTLY CLOSED S[ <br /> ( Pec fY 8) ❑8.TANK REMOVED <br /> ❑6.TEMPORARY SITE CLOSURE 0` <br /> I. FACILITY/SITE INFORMATION (/l0� <br /> BUSBYESSNAME(ST <br /> FACBdTYNAMEorDBA-DoigBusinessAs) 3. FACILITY <br /> WeS� e� L \ O S P ID# T7 <br /> 1. <br /> NEAREST CROSS STREET 401. FACILITY OWNER TYPE ❑4.LOCAL AGENCY/DISTRICT• 402. <br /> 9- ❑1.CORPORATION ❑5.COUNTY AGENCY' <br /> BUSINESS MF I.GAS STATION ❑3.FARM ❑5.COMMERCIAL 403• !2.INDIVIDUAL ❑6.STATE AGENCY* <br /> TYPE [12.DISTRIBUTOR ❑4.PROCESSOR [16.OTHER [13.PARTNERSHIP ❑7.FEDERAL AGENCY* <br /> TOTAL NUMBER OF TANKS 404. Is facility on Indian Reservation 405. 'If owner of UST is a public agency:name of supervisor of division,section or 406. <br /> REMAINING AT SITE or trust lands? office which operates the UST. (This is the contact person for tank records. <br /> 4- e-c- [I Yes IF No J C (c�c�Ct�N �2 `Lks t�o. "l <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE aos. <br /> e -) -7s � N� a09 - g -•3 9 Gq <br /> MAILING OR STREET ADDRESS k 409 <br /> a� t A U V; -e rZ�l <br /> CITY 410, ST E 41L ZIP CODE r <br /> \ Cl qS3�/ ate. <br /> PROPERTY OWNEt TYPE El 1.CORPORATION V2.INDIVIDUAL Lj 4.LOCAL AGENCY/DISTRICT El 6.STATE AGENCY 413. <br /> [13.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> e")e ".-) -� <br /> MAILING OR STREET ADDRESS a16. <br /> a(0 l5 ��a <br /> CITY 417. STATS 418. ZIPI E 419. <br /> TANK OWNER TYP ❑ I.CORPORATION 2.INDIV ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY ago. <br /> ❑3.PARTNERSHIP [15.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY TK) 44- Call 916)322-9669 ifquestions arise 421. <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ❑L SELF-INSURED ❑4.SURETY BOND ❑7.STATE FUND <br /> LOCAL <br /> C]2.GUARANTEE ❑5.LETTER OF CREDIT C]8.STATE FUND&CFO LETTER ❑99.OTR GOVT MECHANISM q„ <br /> [13.INSURANCE ❑6.EXEMPTION ❑9.STATE FUND&CD <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 I or 2 is checked ❑ 1.FACILITY a 2. PROPERTY OWNER [13.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 OF APP ¢ rj DATE 424. 1 PHONE 425. <br /> / �� S 0� X108 -- <br /> NAME OF APPLICANT(print) 426. TITLE OF APPLICANT 427. <br /> e�:,C i,ti -7 q�ff C K C)w ti e 2- <br /> STATE UST FACILITY NUMBER(Agencyuseonly) 428. 1998 UPGRADE CERTIFICATE NUMBER(Agency use only) 429. <br /> (See Data Element I,above. <br /> UPCF Hwfwre-a(1/99)-1/2 http://www.ttnidoes.otg Rev.02/16/00 <br />