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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS - FACILITY (One page per site) Page of_ TYPE OF ACTION ❑1.NEW PERMIT ❑3.RENEWAL PERMIT 5.CHANGE OF INFORMATION ❑7.PERMANENTLY CLOSED SITE 400. (Check one item only) ❑4.AMENDED PERMIT(Specify change) ❑8.TANK REMOVED ❑6.TEMPORARY SITE CLOSURE Y. 'FAGIUFTYI ITIa INFORMATION BUSINESS NAME(same as FACB.ITY NAME or DBA-Doing Business As) 3. FACILITY C r. �� ID# IFIAk 1. i; NEAREST ROSS rSTREET 401. FACILITY OWNER TYPE 4.LOCAL AGENCY/DISTRICT* 402. �`V r�L), P17CORPORATION ❑5.COUNTY AGENCY* BUSINESS 1.GAS STATION El 3.FARM 5.COMMERCIAL 403. [12.INDIVIDUAL ❑6.STATE AGENCY* TYPE ❑2.DISTRIBUTOR [14.PROCESSOR Y6.OTHER ❑3.PARTNERSHIP ❑7.FEDERAL AGENCY* TOTAL NUMBER OF TANKS 404. Is facility on Indian Reservation 405. *If owner of UST is a public agency:name of supervisor of division,section or 406. REMAINING AT SITE or trust lands? office which operates the UST. (This is the contact person for the tank records.) ❑Yes o IJP PROPER O"44NERNFORMATION ? " PROPERTY OWNER NAME 407. PHONE 4011. MAILING OR STREET ADDRESS 409. CITY 410. STATE 411• ZIP CODE 412. PROPERTY OWNER TYPE 0i.CORPORATION 2.INDIVIDUAL 4.LOCAL AGENCY/DISTRICT 6.STATE AGENCY 413. ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY III:TANK OWNER INFOI 11'IATION TANK OWNER NAME 414. PHONE 415. (. ;y.� �,��a' S'10 - c%- 1 MAILING OR STREET ADDRESS 416. a� r,m ��rr�v��le � , CITY 417. STATE 418. 1 ZIP COD 419. zon TANK OWNER TYPE ORPORATION 2.INDIVIDUAL Lj 4.LOCAL AGENCY/DISTRICT 6.STATE AGENCY 420. ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY r, W.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY TK HQ 44- 10 101 10 1 1 b 1 6 1 Call 916 322-9669 ifquestions arise 421 7,V:PETROLEUM UST'FINANCIAL RESPONSIILITYoe INDICATE METHOD(s) W.SELF-INSURED ❑4.SURETY BOND ❑7.STATE FUND ❑10.LOCAL GOV'T MECHANISM 422. [12.GUARANTEE ❑5.LETTER OF CREDIT ❑8.STATE FUND&CFO LETTER ❑99.OTHER: ❑3.INSURANCE ❑6.EXEMPTION ❑9.STATE FUND&CD AFI,LEGALN"OTIFICATI(?N; SAILING ADDRESS �., v Check one box to indicate which address should be used for legal notifications and mailing. Legal notifications and mailings will be sent to the tank owner unless box 1 or 2 is checked. ❑ 1.FACILITY ❑2. PROPERTY OWNER TANK OWNER 423. a VII.APPLICANT SIGNATUIIkE; Certification: I certify that the information provided herein is true and accurate to the best of my knowledge. SIGNATURE OF APPLICANT DATE 424, PHONE 47711. F - C NAME OF APPLICANT(print) 426. TITLE OF APPLICANT 4277 errs t9o�1,7r A%/, rk STATE UST FACILITY NUMBER(Agency use only) 428. 1998 UPGRADE CERTIFICATE NUMBER(Agency use only) 429. (See Data Element 1,above. UPCF Hwfwrc-a(1/99)-1/2 www.unidocs.org Rev.02/16/00