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UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page per site) <br /> Page _ of _ <br /> TYPE OF ACTION I 1.NEW SITE PERMIT F 3.RENEWAL PERMIT I 5.CHANGE OF INFORMATION(Specify change- I T PERMANENTLY CLOSED SITE <br /> (Check one item only) F 4.AMENDED PERMIT local use only) I 8.TANK REMOVED 400 <br /> IF 6.TEMPORARY SITE CLOSURE <br /> 1.FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 FACILITY ID* <br /> YOSO'4ITE" PSVc ­_Ats�J O 4 Z <br /> NE'ARRS T CROSS STREET 401 _ FACILITY OWNER TYPE F 4. LOCAL AGENCY/DISTRICT- <br /> 1001 <br /> GENCY/DISTRICT' <br /> `v0 t & yose^►n. F 1. CORPORATION F 5. COUNTY AGENCY- <br /> BUSINESS TYPE 1.GAS STATION F 3.FARM F 5.COMMERCIAL F 2. INDIVIDUAL <br /> F 6. STATE AGENCY' <br /> r 2.DISTRIBUTOR r 4.PROCESSOR r 6.OTHER 3. PARTNERSHIP r 7. FEDERAL AGENCY- 402 <br /> 403 <br /> TOTAL NUMBER OF TANKS Is facility on Indian Reservation or 'If owner of UST is a public agency:name of supervisor of _ <br /> REMAINING AT SITE trusllands? division,section or office which operates the UST. <br /> (This is the contact person for the tank records.) <br /> 404 I Yes I No 405 406 <br /> It.PROPERTY OWNER INFORMATION p <br /> PROPERTY OWN NM4<)k 27 TN C. Cq PHONE <br /> 408{y s-Q �s <br /> MAILING OR STREET ADDRESS 409 <br /> y2_43 KN oQ LVI&,) _D2 <br /> CITY 410 STATE 411 ZIP CODE 412. <br /> Z)PrLL 0-^tJ V 1� 9 LbsO (1z, <br /> PROPERTY OWNER TYPE 2. INDIVIDUAL F 4. LOCAL AGENCY/DISTRICT I'6. STATE AGENCY 413 <br /> F 1. CORPORATION I 3. PARTNERSHIP F 5. COUNTY AGENCY I 7. FEDERAL AGENCY <br /> III,TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> _pA9-kV- _0JC_ (9i5) Sys-a185 <br /> MAIL F`OR STREET ADDRESS 1 <br /> •lrV4;�j L� �Q- <br /> CITY 417 STATE 418 ZIP CODE 419 <br /> `)P(V�V i L-LE I C* I 9'� 5o <br /> TANK OWNER TYPE 2. INDIVIDUAL F 4. LOCAL AGENCY/DISTRICT F 6. STATE AGENCY 420 <br /> I' 1. CORPORATION I 3. PARTNERSHIP F 5. COUNTY AGENCY I' 7. FEDERAL AGENCY <br /> TY(TK)HQ 4 F4 - d Call(916)322-9669 if questions arise 421 <br /> INDICATE METHOD(S) I 1. SELF-INSURED I 4. SURETY BOND W 7. STATE FUND I 10. LOCAL GOV=T MECHANISM <br /> �/1 I 2. GUARANTEE I 5. LETTER OF CREDIT F 8. STATE FUND&CFO LETTER F 99. OTHER: <br /> IF 3. INSURANCE r 6. EXEMPTION I' 9. STATE FUND&CD 422 <br /> V11 I IEGAII NOTIFICA110M AND MAILING ADDRESS <br /> Check one box to indicate which addtess should be used for legal notifications and mailing€ r 1. FACILITY I 2. PROPERTY OWNER I 3. TANK OWNER 423 <br /> Le al notifications and mailin swill nt to the tank owner unless box 1 or 2 is checked. <br /> Certification: I ceftify hal the information provided herein is true and accurate to the best of my knowledge. _ <br /> IGNAT F DATE <br /> /O O+� zj <br /> 424 P ONEC/(C,P) Y) _ S 2425 <br /> E 0 PL AN (print) 426 TI LE OF APPLICANT 427 <br /> L C - �= T <br /> STATE UST FACILITY NUMBER(For local use only) 428 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 <br /> UPCF(1199 revised) 5 Formerly SWRCB Form A <br />