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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 ACTION ❑ 1. NEW SrIE PERMrr ❑ 3. RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7YERMANENTLY CLOSED SITE <br />(Check one item only) ❑ 4. AMENDED PERMIT specify change local use only ❑ 8. TANK REMOVED <br />❑ &TEMPORARY s1TE CLOSURE 400 <br />I. FACILITY / SITE INFORMATION <br />BUkINESS NAME (Same as FAMITY NAME or DBA -Doing Businen As) 3 <br />FACILITY ID# <br />]:]�4. <br />NEAkEST CROSS S _� 401 <br />FACILITY OWNER TYPE LOCAL AGENCY/DISTRICT' <br />i i, kt (/ <br />® `1-tORPORATION ❑ 5. COUNTY AGENCY* <br />❑ 2. INDIVIDUAL ❑ 6. STATE AGENCY* <br />BUSINESS In 1. GAS STATION Lj 3. FARM U 5. COMMERCIAL <br />TYPE ❑ 2. DISTRIBUTOR ❑ 4. PROCESSOR ❑ 6. OTHER 4o3 <br />❑ 3. PARTNERSHIP ❑ 7. FEDERAL AGENCY' 402 <br />TOTAL NUMBER OF TANKS <br />Is facility on Indian Reservation or <br />alf owner of UST is a public agency: name of supervisor of division, section or office which <br />REMAINING AT SITE <br />trustlands? <br />operates the UST (Chis is the contact person for the tank records.) <br />404 <br />❑ Yes ❑ No 405 <br />406 <br />II. PROPERTY OWNER INFORMATION <br />PROPERTY OWNER NAME r 403 <br />PHONE _ 409 <br />MAILING OR STREET ADDRESq 409 <br />j <br />�L1 (`_ �I �w <br />CITY 410 <br />,c, <br />STA 4 411 <br />ZIP CODE 412 <br />PROPERTY OWNER TYPE ULCORPORATION 2. INDIVIDUAL 4. LOCAL AGENCY/ DISTRICT LJ6.STATEAGENCY <br />[13. PARTNERSHIP [35. COUNTY AGENCY ❑ 7. FEDERAL AGENCY 413 <br />III. TANK OWNER INFORMATION <br />TANK OWNER NAME 414 <br />PHONE 415 <br />MAILING OR STREET ADDRESS 416 <br />CITY 417 1 <br />STATE 418 <br />ZIP CODE 419 <br />TANK OWNER TYPE 0 1. CORPORATION ❑ 2. INDIVIDUAL [14. LOCAL AGENCY / DISTRICT ❑ 6. STATE AGENCY 420 <br />[13. PARTNERSHIP [15. COUNTY AGENCY ❑ 7. FEDERAL AGENCY <br />W. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br />TY TK HQ 44- Call 916 322-9669 if uestions.arise 421 <br />_ _ _ <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br />INDICATE METHOD(s) [11. SELF-INSURED ❑ 4. SURETY BOND ❑ 7. STATE FUND ❑ 10. LOCAL GOVT MECHANISM <br />❑ 2. GUARANTEE ❑ 5. LETTER OF CREDIT ❑ 8. STATE FUND & CFO LETTER ❑ 99. OTHER: <br />[13. INSURANCE ❑ 6. EXEMPTION ❑ 9. STATE FUND & CD 4n <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 l or 2 is checked ❑ 1. FACILrrY ❑ 2. PROPERTY OWNER ❑ 3. TANK OWNER 423 <br />VII. APPLICANT SIGNATURE <br />Certification -1 ccrtify that the information provided herein is true and accurate to the best of my knowledge. <br />SIGNATU�E OF APPLICANT , . l % <br />; r <br />DATE 4R <br />PHONE 425 <br />1 <br />;(/ - <br />NAM - APPLICANT (print) 426 <br />TMEbf APPLICANT 427 <br />STATE UST FACILITY NUMBER (For total use only) 428 <br />1998 UPGRADE CERTIFICATE NUMBER (For beat use oAy) 429 <br />UPCF (1/99 revised) 8 Formerly SWRCB Form A <br />