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UNIFIED PROGRAM CONSOLIDATED FORM <br /> ' TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page per site) Page_of <br /> TYPE OF AC T1Cr Ej 1 NEW Si`"E PERMIT ❑3.RENEWAL PERMI' j3.-RANGE OF INFORMATION Q 7.PERMANENTLY CLOSED SITE <br /> (Check one item only) 0 4 AMENDED-E2MIT specify change local use only_.__ , _ (] S.TANK RFMOVBD <br /> o TEMPORARY SITE CLOSURE 400 <br /> I. FACILITY 1 SITE INFORMATION <br /> � INESSNANIF ( ameasFAC t.rYNAMEor09A Doing FACILhrY ID# <br /> BU5 <br /> NELLA 06 Company #427 i _ ii �r <br /> NEAREST CROSS STREET 4ci FACILITY OWNER TYPE ❑4. LOCAL GENCY/DISTRICT- <br /> Report Ave ❑ I.CORPORATION C 5 COUNTY AGENCY" <br /> BUSINESS n - GAS STATION ] 3 FARM (�5. C.OSAL ❑ 2. INDIVIDUAL E]E STATE AGENCY' <br /> TYPE [12. DISTRiBU?OR ❑4 PROCESSOR[; 6. =HEP „ 3.PARTNERSHIP ❑7 FEDERALAGENCY' 402 <br /> TOTAL NUMBER OF TANKS Is facility on Indian Reservation or 'If owner or UST s a public agency came of supervisor of division,section or office <br /> REMAINING AT SITE trustlands? which operates the UST(T7is is the rontact'person for the tank records.) <br /> 3 404 E] Yeas Q No Ds 406 <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERNAIVE .� r�- PHONE <br /> ? aoa <br /> Quentin Kirsch � 713 744 4152 <br /> _.._._i <br /> MAILING OR STREET __.__ <br /> 409 I <br /> 190 Amber,Way <br /> CITY — - - „?i STATE 411 ZIP CODE ate I <br /> Hanford CA 93230 _ _ <br /> PROPERTY 1:U�ER TY5F'C? 1 CC?RPORATION 2 INDIVIDI AI_ ❑4. LOCAL AGENCY/DISTRICT 6 STATE_ AGENCY <br /> ❑ 3 PART JFRSHIP [15. COUNTY AGENCY ❑ T FEDERAL ata <br /> III. TANK OWNER INFORMATION <br /> _ , <br /> a14 PHONE 415 <br /> NELLA Oil C^rnpany 530 885-0401 <br /> MAILING OR STREET-ADDRESS ----- .____._.. . ___, 470 ! <br /> 2349 RlcKenNacker lVay _� __ ___ . <br /> CITY STATE y ZIP.-OCE <br /> 4!9 ! <br /> Auburn _ CA 95602 1 <br /> ��AKOVINE r� E COf� nRATIvN 2 hiDl�/I )l AL _T_.ISTRICT.-- _ ----— �TAfE AC <br /> PART'N_RSHIP [15.COUNTY AGENCYCY I 717 <br /> 71 7 FEDERAL AGENCY <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER I <br /> �TY (TK') NQ 41 ' - 8 9 Call (916 322-9669 If <br /> .�.---. _ ----.,`?.___ _l. . - � ., ) questions arse 42, " <br /> I V. PETROLEUM LIST FINANCIAL RESPONSIBILITY <br /> INDICATE ❑ I SELF-INSURED ❑4.SURETY BOND [] 7.STATE FUND- -- -x ❑ 10 LOCAL GOVT MECHANISM <br /> METHOD(s) _l GUARAN rEE ❑5. LETTER OF CREDIT ®8.STATE FUND&CFO LETTER ❑ 99. OTHER <br /> ❑ 3 INSURANCE [16. EXEMPTION ❑9. STATE FUND&CD 422 <br /> Ia VI. LEGAL NOTIFICATION AND MAILING ADDRESS <br /> ��-- --- - <br /> '_— ' <br /> ! Check <br /> one t <tc nCEcate which address should he used for legal^oi f atrors ono ma,ing. <br /> Lega! notir ar c,ns rr;ail rgs will oe sent the tank cwnf, unless Lox :;r 7 is.:I-ecked. Q 1 FACILITY ®2 PROPERTY OWNER EI 3.TANK 423 <br /> OWNER <br /> VII. APPLICANT SIGNATURE <br /> h, <br /> I Certificatwn I F ta'tie.r,form , r provided herein is true and accurate to rhe hest of my knowledge Tmm— <br /> SIGNAIURE <br /> DATE 42a PHONE - — 425 <br /> � !01 530-885-0401 <br /> _._ _ _ I <br /> NAME GF ?PP ANnnn <br /> T �t - -- - a g TITLE OF APPLICANT —".1 Jack <br /> 'Director of E- 7lreerlr'C <br /> ST.AiE J = FF _ 19;5 6PGRr+0c -iCAT- `..1P.rlPE? ca'• 425 <br /> r�, <br />