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At <br /> r UNIFIED PROGRAM CONSOLIDATED FO _ <br /> 4 <br /> r TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (One page per site) Page_of <br /> TYPE OF ACTION NEW PERMIT ❑3.RENEWAL PERMIT X5.CHANGE OF INFORMATION ❑7.PERMANENTLY CLOS S <br /> a00. <br /> TE <br /> (Check one item only) ❑4.AMENDED PERMIT (Specif change) ❑8.TANK REMOVED 1 <br /> ❑6.TEMPORARY SITE CLOSURE <br /> L -FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Same as FACILrrY NAME or DBA-Doing Business As) 3. FACILITY <br /> ID# P4. <br /> NEAREST CROSS STREET 401. FACILITY OWNER TYPEAL AGENCY/DISTRICT* <br /> CORPORATION ❑5.COUNTY AGENCY* ( I <br /> BUSINES 1.GAS STATION ❑3.FARM 5.COMMERCIAL 403. ❑2.INDIVIDUAL El 6.STATE AGENCY* <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR ❑6.OTHER ❑3.PARTNERSHIP ❑7.FEDERAL AGENCY* <br /> TOTAL NUMBER OF TANKS 404. Is facility <br /> ao5. 'If owner of UST is a public agency:name of supervisor of division,section or 406. <br /> REMAINING AT SITE or trust lands?Indian Reservation office which operates the UST. (This is the contact person for the tank records.) <br /> 3 ❑Yes o <br /> "II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 408. <br /> Rt C 2r' S f4YV� 132 �� 2 U cf� ��'� " � 3 <br /> 409. <br /> MAILING OR STREET ADDRESS <br /> bi AML ; <br /> CITY 41°. 'STATE 411. ZIP CODE 412. <br /> G� �153 �r0 <br /> PROPERTY OWNER TYPE ❑ 1.CORPORATION 2.INDIVIDUAL 0 4.LOCAL AGENCY/DISTRICT Lj 6.STATE AGENCY <br /> 413. <br /> ❑3.PARTNERSHIP [15.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> IILTANK OWNER INFORMATION <br /> TANK OWNER NAME ala. PHONE _ 415. <br /> StyVFieH4w1� r�lC, 20q 2&-�cf <br /> 416. <br /> MAILING OR STREET ADDRESS <br /> 'W1060 <br /> CITY 417. STATE 418. 1 ZIP CODE C7 S2 r 0 419. <br /> -rd tK-roti. Gi4 <br /> TANK OWNER TYPE 1.CORPORATION ❑2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT El6.STATE AGENCY ago. <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- ii 1 Call(916)322-9669 if questions arise 421. <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) [11.SELF-INSURED ❑4.SURETY BOND ❑7.STATE FUND ❑10.LOCAL GOVT MECHANISM 422. <br /> ❑2.GUARANTEE [15.LETTER OF CREDIT ❑8.STATE FUND&CFO LETTER ❑99.OTHER: <br /> ❑3.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. X 1.FACILITY C12. PROPERTY OWNER [13.TANK OWNER 423. <br /> VII.APPLICANT SIGNATURE <br /> Certification: I certify that the informatio rovi& herein is true and accurate to the best of my knowledge. <br /> DAT 424. PHONE G425. <br /> SIGNATURE OF APPLICANT +( O� 2 p c , �O <br /> VN tTi O an. <br /> NAME OF APPLICANT( rint) 426. TITLE OF APPLICANT <br /> STATE UST FACILITY NUMBER(Agency use only) <br /> azs. 1998 UPGRADE CERTIFICATE NUMBER(Agency use only) 429' <br /> (See Data Element 1,above. <br /> UPCF Hwfwrc-a(1/99)-1/2 <br /> http://www.unidocs.org Rev.02/16/00 <br />