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Y <br /> 0 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> T <br /> UNDERGROUND STORAGE TANKS - FACILITY t <br /> (one page per site) Page_o <br /> TYPE OF ACTION 1.NEW SITE PERMIT' ❑3.RENEWAL PERMIT S.CHANGE OF INFORMATION ❑ 7.PERMANENTLY CLOSED SI PIF <br /> (Check one item only) ❑4.AMENDED PERMIT specify change local use only ❑ 8.TANK REMOVED <br /> ❑&TEMPORARY SITE CLOSURE 400 <br /> 1. FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Samem FACILITY NAME or DBA-Doing Business As) ; 1 FACILITY ID# I J___[Tj <br /> d-T O.D <br /> AREST CROSS STREET 401 FACILITY OWNER TYPE 4.LOCAL AGENCY/DISTRICT* <br /> A)457 [� 1.CORPORATION ❑5.COUNTY AGENCY* <br /> BUSIMES'SO 1.GAS STATION 3.FARM S. COMMERCIAL 6 2.INDIVIDUAL ❑6.STATE AGENCY* <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR 6. OTHER 4o3 ❑ 3.PARTNERSHIP ❑7.FEDERAL AGENCY* 402 <br /> TOTAL NUMBER OF TANKS Is facility on Indian Reservationof *If owner of UST is a public agency:name of supervisor of division.section or office which <br /> REMAINING AT SITE trustlands? operates the UST(This is the contact person for the tank records.) <br /> 4(m0 Yes (A No 4115 406 <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 1 PHONE 4W <br /> 90,?-23 -7y <br /> MAILING OR STREET ADDRESS 409 <br /> 1 410 STATE 411 ZIP CODE 412 <br /> i91'7 n/Std /v O . / <br /> PROPERTY OWNER TYPE TKI.CORPORATION 2.INDIVIDUAL 4.LOCAL AGENCY/DISTRICT Ll 6.STATE AGENCY <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY 413 <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE415 <br /> -�e-- v <br /> MAILING OR STREET ADDRESS 4I6 <br /> CITY 417 STATE . 418 ZIP COD 419 <br /> TANK OWNER TYPE 1.CORPORATION 0 2.INDIVIDUAL 4.LOCAL AGENCY/DISTRICT 1716.STATEAGENCY 420 <br /> ❑3.PARTNERSHIP ❑S.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY TK HQ 44- 1 Q Call 916 322-9669 if questions arise 421 <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) 1.SELF-INSURED ❑4.SURETY BOND ❑7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM <br /> 9 2.GUARANTEE ❑5.LETTER OF CREDIT ❑8.STATE FUND&CFO LETTER ❑ 99.OTHER: <br /> ❑3.INSURANCE. ❑6.EXEMPTION [19.STATE FUND&CD 422 <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one box to indicate which address should be used for legal ratifications and mailing. <br /> Legal notifications and mailings will be sent to the tank owner unless box I or 2 is checked. ❑ I.FACILITY ❑2. PROPERTY OWNER ❑3.TANK OWNER 423 <br /> VII.APPLICANT SIGNATURE <br /> Certification-I certify that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNATU • FAPP ANT DATE 424 PHONE 4s <br /> NA OF APPL7( 1 <br /> T(print) 426 TITLE OF APPL CANT 4n <br /> e. <br /> STATE UST FACILITY NUMBER(Forlocal usconly) 428 1998 UPGRADE CERTIFICATE NUMBER(Forlowl usconly) 429 <br /> UPCF(1/99 revised) 8 Formerly SWRCB Form A <br />