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UNIFIED PROGRAM CONSOLIDATED FORM <br /> F- r Z TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page per site) <br /> Page _ of _ <br /> TYPE OF ACTION F 1.NEW SITE PERMIT I 3.RENEWAL PERMIT CHANGE OF INFORMATION(Specify change- r 7.PERMANENTLY CLOSED SITE 0! <br /> (Check one item only) t r 4.AMENDED PERMIT local use only) fl1�14�✓� r 8.TANK REMOVED 400 y�!J`y�yf' <br /> F 6.TEMPORARY SITE CLOSURE <br /> I.FACILITY I SITE INFORMATION <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 FACILITY ID# <br /> F_Co >`No C.-, *% s IF 4° 3g6 <br /> NEAREST CROSS STR T 401IA1 FACILITY OWNER TYPE r 4. LOCAL AGENCY/DISTRICT- <br /> 1 C\ Irl% v pp $V t C F 1. CORPORATION F 5. COUNTY AGENCY` <br /> BUSINESS TYPE I'✓ Us STATION F 3.FARM 1 5.COMMERCIALr INDIVIDUAL F 6, STATE AGENCY- <br /> r 2.DISTRIBUTOR F 4.PROCESSOR F G.OTHER 3. PARTNERSHIP F 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 SITEs� trustlands7 division,section or office which operates the UST. <br /> f. ✓• (This is the contact person for the tank records.) <br /> 404 F Yes F No 405 406 <br /> II.PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408 <br /> S C S �_ 'to ! �I16 gat - S' 77 � <br /> MAILING OR STREET ADDRESS 409 <br /> iso \( t '_A <br /> CITY 410 STATE 411 21P CODE 412 <br /> d.oa: C, c a c,5z �' � <br /> PROPERTY OWNER TYPEr,-.2.�INDIVIDUAL r 4. LOCAL AGENCY/DISTRICT F 6. STATE AGENCY 413 <br /> RL <br /> I 1. CORPORATION PARTNERSHIP F 5. COUNTY AGENCY I 7 FEDERAL AGENCY <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> S tiiG. V1 S v, �1 9 16-8 of - 7 7 <br /> MAILING OR STREET ADDRESS 416 <br /> do �a g� �`��sc � <br /> CIN 417 STATE 418 1 ZIP CODE 419 <br /> c � �S24d <br /> TANK OWNER TYPE I� 2. INDIVIDUAL F 4. LOCAL AGENCY/DISTRICT I' 6. STATE AGENCY 420 <br /> I 1. CORPORATION i f ePARTNERSHIP IF 5. COUNTY AGENCY F 7. FEDERAL AGENCY <br /> V �JAJD OE E I IAI lZA110M I ISI STORAGE FEE A - I RFR <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 BONDr 7. ST TE FUND r 10. LOCAL GOV=T MECHANISM <br /> I 2. GUARANTEE I 5. LETTER OF CREDIT I�TE FUND&CFO LETTER I 99. OTHER: <br /> I 3. INSURANCE r 6. EXEMPTION r 9. STATE FUND&CD 422 <br /> Check one box to indicate which address should be used for legal notifications and mailing. I 1. FACILITY I 2. PROPERTY OWNER I 3. TANK OWNER 423 <br /> Least notifications and ma= <br /> s will be sent to the tan own unlessx 1 r i <br /> MANI SIGNATURE <br /> Certification: I certify that the information provided her'n i6 true and accurate to the best of my knowledge. <br /> SIGNATURE OF APPLICANT i ^ DATE a�24 PHON /6 _ J02 <br /> y _ c 7 7 425 <br /> \� l f. J <br /> NAME OF APPLICANT(print) 426 TITLE OPAPPI ICA 427 <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 />