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f <br /> V <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page per site,) <br /> Page _ of _ <br /> TYPE OF ACTION F 1.NEW SITE PERMIT F 3.RENEWAL PERMIT r 5.CHANGE OF INFORMATION(Specify change- F T PERMANENTLY CLOSED SITE <br /> (Check one item only) 4.AMENDED PERMIT local use only) F 8.TANK REMOVED 400 <br /> F <br /> r 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 /> W11-So �/ �U �'��X11�' <br /> NEAREST CROSS STREET 401 FACILITY OWNER TYPE F 4. LOCAL AGENCY/DISTRICT- <br /> Cor 7 r 1. CORPORATION F S. COUNTYAGENCY` <br /> BUSINESS TYPE Z4 GAS STATION F 3.FARM r 5.COMMERCIAL r 2. INDIVIDUAL F 6. STATE AGENCY- <br /> 2.DISTRIBUTOR r 4.PROCESSOR r 6.OTHER r 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 trustlands? division,section or office which operates the UST. <br /> (This is the contact person for the tank records.) <br /> 404 Yes F No 405 406 <br /> II.PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408 <br /> MAILING OR STREET ADDRESS 409 <br /> G/,,77 A I,SC IV SO Al IIIA ;,"cckro N c 4 q5 �� G <br /> CITY 410 STATE 411 ZIP CODE 412 <br /> PROPERTY OWNER TYPE r INDIVIDUAL F 4. LOCAL AGENCY/DISTRICT F 6. STATE AGENCY 413 <br /> r 1. CORPORATION F 3. PARTNERSHIP r 5. COUNTY AGENCY F 7. FEDERAL AGENCY <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> 9itY) a7d.?�)- 5)r 6A/ JVU 26e --9017, ° "314 <br /> MAILING OR STREET ADDRESS 416 <br /> //:) ;?- Al Clef Y L*eke 7' Af C,' <br /> CITY 417 STATE 418 ZIP CODE 419 <br /> TANK OWNER TYPE F . INDIVIDUAL r 4. LOCAL AGENCY/DISTRICT F 6. STATE AGENCY 420 <br /> F 1. CORPORATION F 3. PARTNERSHIP r 5. COUNTY AGENCY F 7. FEDERAL AGENCY <br /> TY(TK)HQ 4 4 - Call(916)322-9669 if questions arise 421 <br /> INDICATE METHOD(S) r 1. SELF-INSURED F 4. SURETY BOND F 7. STATE FUND F 10. LOCAL GOV=T MECHANISM <br /> r 2. GUARANTEE r 5. LETTER OF CREDIT F 8. STATE FUND&CFO LETTER F 99. OTHER: <br /> r 3. INSURANCE F 6. EXEMPTION r 9. STATE FUND&CD 422 <br /> Check one box to indicate which address should be used for legal notifications and mailing. F 1. FACILITY F 2. PROPERTY OWNER F 3. TANK OWNER 423 <br /> Legal notifications and mailings will be sent to the tank owner unless box 1 or 2 is <br /> Certification: I certify that the information provided herein is We and accurate to the best of my knowledge. <br /> S NATURE OF IC DATE 424 1 PHONE 425 <br /> E OF APPLICANT(print) 426 TITLE OF APPLICANT 427 <br /> sae) yr S' <br /> STATE UST FACILITY NUMBER(For local use only) 428 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 <br /> UPCF(1/99 revised) 5 Formerly SWRCB Form A <br />