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UNIFIED PROGRAM CONSOLIDATED FORM D�E <br /> J_M /7 C <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> I (one pagAki )1 4J .f <br /> TYPE OF ACTION ❑ 1.NEW SITE PERMIT 0 3.RENEWAL PERMIT 0 5.CHANGE OF INFORMATION 0 <br /> (Check one item only) 4.AMENDED PERMIT specify change local use only ❑ S.Tft"Mr/ftRVICB <br /> 0&TEMPORARY SITE CLOSURE 400 <br /> I. FACILITY/SITE INFORMATION <br /> BUSINESS NAME(S...cu FACILITY NAMEor DBA-Doin,Business As) 3 FACILITY ID# <br /> NEAREST CROSS STREET 401 FACILITY OWNER TYPE Ej 4.LOCAL AGENCY/DISTRICT* <br /> 0 1.CORPORATION [15.COUNTY AGENCY* <br /> BUSINESS [11.GAS STATION ❑3.FARM 5. COMMERCIAL El 2.INDIVIDUAL El 6.STATE AGENCY* <br /> TYPE El 2.DISTRIBUTOR ❑4.PROCESSOR 6. OTHER 403 Ej 3.PARTNERSHIP D 7.FEDERAL AGENCY* 402 <br /> TOTAL NUMBER OF TANKS Is facility on Indian Reservation or *If owner of UST is a public agency:name of supervisor of division,section or office which <br /> REMAINING AT SITE trustlands? operates the UST(This is the contact person for the tank records.) <br /> 404 0 Yes N 0 403 1 4W <br /> 11. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME Q8 <br /> j <br /> L_CC M le-mo r 1" CL D 11 aos 339 - -7tdo <br /> MAILIj3G OR STREADDRESS <br /> CITY 410 STATE,Ltx411 1 ZIP CODE 412 i4 Cq-5,9 c/ <br /> PROPERTY OWNER TYPE Ell.CORPORATION 02.INDIVIDUAL 0 4.LOCAL AGENCY/DISTRICT 0 6.STATE AGENCY <br /> E-1 3.PARTNERSHIP [15.COUNTY AGENCY [3 7.FEDERAL AGENCY 413 <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> ,-In <br /> HD (1,2ool) 3MI 7LQC0--) 416 <br /> MAILIG OR STREET ADDRESS <br /> CITY j-,i L-OcI 417 1 STATE 418 ZIP CORE 419 <br /> t <br /> TANK OWNER TYPE El 1.CORPORATION -0,2.INDIVIDUAL 0 4.LOCAL AGENCY DISTRICT Lj 6.STATE AGENCY 420 <br /> Q 3.PARTNERSHIP C3 5.COUNTY AGENCY 0 7.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44--j 1 1 1 1 1 Call(916)322-9669 if questions arise 421 <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(> 1.SELF-INSURED [:14.SURETY BOND El 7.STATE FUND El 10.LOCAL GOVT MECHANISM <br /> E]2.GUARANTEE El S.LETTER OF CREDIT [18.STATE FUND&CFO LETTER El 99.OTHER: <br /> El 3.INSURANCE 0 6.EXEMPTION El 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 I or 2 is chocked. ❑ 1,FACILITY PROPERTY OWNER C33.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 /> WNATURE OF APPLICANT DATE 424 1 PHONE 425 <br /> U11c) 9'77- <br /> NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 427 <br /> ' STATE LIST FACILITY NUMBER(For local use only) 428 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 <br /> UPCF(1/99 revised) 8 Formerly SWRCB Form A <br />