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UNIFIED PROGRAM CONSOLIDATED FORM <br /> l <br /> UNDERGROUND STORAGE TANKS - FACILITY TANKS <br /> ( *p e) Page_of_ i�- <br /> TYPE OF ACTION ❑ L NEW SITE PERMIT ❑3.RENEWAL PERMIT 3krCHANGE OF INFORMATION 0'1.PrkMA_NrNTLY CLOSED SITE <br /> (Check one item only) ❑4.AMENDED PERMIT specify change local use only Q 8 TA MOVED <br /> +t {i i 'dd11 T <br /> ❑&TEMPORARY SITE CLbS T V , s n;:- - i Opp <br /> L FACILITY/SITE INFORMATJ&& L T it DEPARTMENT <br /> BUSINESS N E(Same as FACILITY NAME or DBA-Doing Business As) 3 FACILITY ID# <br /> R-c O 6v S Kc -L_ ' <br /> NEAREST CRSS STS YT --. aol FACILITY OWNER TYPE ❑4.LOCAL AGENCY/DISTRICT* <br /> 1 �F �t_j•► AI I E. 'r ❑ 1.CORPORATION ❑5.COUNTY AGENCY* <br /> BUSINESS GAS STATION ❑3.FARM ❑5. COMMERCIAL @,e`I` _DIVIDUAL ❑6.STATE AGENCY* <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR[16. OTHER 403 ❑ 3.PARTNERSHIP ❑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 ❑ Yes V.1d'15" 405 1 N A 406 <br /> II. PROPERTY OWNER INFORMATION !T <br /> PROPERTY OWNER NAME 4113 PHONE 408 <br /> RN A I, .Ik 7..1. A N Cq L-E C_-f E f A �' �4 N 6t 1. zo 4 4-s-I f <br /> MAILING OR STREET ADDRESS <br /> 3 *( l:. • M l4 1 N S+-I 2-l 10 t•! 4119 <br /> CITY au1 STATE all ZIP CODE 412 <br /> Q-LPI) C_ t I'Y 366 <br /> PROPERTY OWN"[]�J❑p1.CORPORATION NDIVIDUAL El 4.LOCAL AGENCY/DISTRICT 6.STATE AGENCY <br /> �"^"+R OF- ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY 413 <br /> III.TANK OWNER INFORMATION <br /> TANK OWt3 AAI E�` 7� G K � A- �� �C ala PHONE O als <br /> }- �L '7 <br /> MAILING OR STREET ADDRESS alb <br /> 3 J 17%- . <br /> CIT C MON I alz STATE C <br /> rt --iIx ZIP CODEr �J 419 <br /> TANK OWNER TYPE ❑ 1.CORPORATION INDIVIDUAL ❑4.LOCALAGENCY/DISTRICT <br /> - ❑6.STATE AGENCY ago <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY [17.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- Call 916 322-9669 if questions arise <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ❑ I.SELF-INSURED ❑4.SURETY BOND ❑7.SS FUND ❑ 10.LOCAL GOVT MECHANISM <br /> ❑2.GUARANTEE [:15. LETTER OF CREDIT N41STATE 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 I or 2 is checked. ❑ 1.FACILITY ❑2. PROPERTY OWNER ANK OWNER 423 <br /> VII.APPLICANT SIGNATURE <br /> Certification-1 certify that the information Eviled he in is true and accurate to the best of in knowledge. <br /> SIGNATURE OF APPLICANT i DATEPHONE 425 <br /> I o <br /> NAME OF��APPLICANT d� 4226p TIT OF APPLICANT an <br /> STATE UST FAC ITY NUMBER(to6ocal use only) 428 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 <br /> UPCF(1/99 revised) 8 Formerly SWRCB Form A <br /> i <br />