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UNIFIED PI-.OGRA W CONSOLIDATED FORM <br /> TANKS ^� <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (One page per site) Page 1 of <br /> TYPE OF ACTION 1.NEW PERMIT ❑3.RENEWAL PERMIT ❑5.CHANGE OF INFORMATION400. <br /> (Specify(Check one item only) ❑4.AMENDED PERMIT S e ❑7.PERMANENTLY CLOSED SITE <br /> ( p fy chang) ❑8.TANK REMOVED t <br /> ❑6.TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION <br /> `Ofr <br /> BUSINESS NAME(Sane as FACILITY NAME or DBA-Doing Business As) 3, FACILIT/Y�. <br /> Dl t ti ID# <br /> NQAREST CROSS STREE•t 401. FACILITY OWNER TYPE 4.LOCAL AGENCY/DISTRICT* 402. <br /> ElI.CORPORATION ❑5.COUNTY AGENCY* <br /> BUSINESS Ll 1.GAS STATION El 3.FARM 5.COMMERCIAL 403• ❑2.INDIVIDUAL EZ 6.STATE AGENCY* <br /> TYPE ❑2.DISTRIBUTOR [:14.PROCESSOR V 6.OTHER ❑3.PARTNERSHIP ❑7.FEDERAL AGENCY* <br /> TOTAL NUMBER OF TANKS 404• FOfaYes <br /> cility on Indian Reservation 405. *If owner of UST is a public agency:name of supervisor of division,section or 406. <br /> REMAINING AT SITE ust lands? office:which operates the UST. (This is the contact person for the tank records.) <br /> ; No t�b <br /> II. PROPERTY OWNERINFORMATION <br /> P OP TY OWNER NAME ( aoz PHONE _ 408. <br /> MAILING OR STREET A13DRESS 1 409 <br /> CITlj`C 410. STATE all. ZIP CODE a 5_O l ate, <br /> PROPERTY OWNER TYPE U 1.CORPORATION 2.INE 0 4.LOCAL AGENCY/DISTRICT 6.STATE AGENCY 413. <br /> ❑3.PARTNERSHIP [15.COUNTY AGENCY 7.FEDERAL AGENCY <br /> III,TANK.OWNER INFORMATION <br /> TANK OWNER NAME ala. PHONV ZO Y:jfilLrA - a <br /> r 6 ,� I .--i1 r4 q c' <br /> MAILING OR STREET ADDR SS k 416. <br /> CITY P-ro alz STAT 418. ZIP CODE 419. <br /> 9 S tQj <br /> TANK OWNER TYPE 1.CORPORATION 2.INDIVIDUAL 4.LOCAL AGENCY/DISTRICT 6.STATE AGENCY 420. <br /> 3.PARTNERSHIP [:15.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> IV.BOARD OI+ EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY K HQ 44- 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 422. <br /> [12.GUARANTEE ❑5.LETTER OF CREDIT ❑8.STATE FUND&CFO LETTER 99.OTHER: <br /> ❑3.INSURANCE ❑6.EXEMPTION ❑9.STATE FUND&CD <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 I or 2 is checked. 1.FACILITY ❑2. PROPERTY OWNER ❑3.TANK OWNER 423• <br /> VII.APPLICANT SIGNATURE <br /> Certification: I certify that the info-t• provided herein is true and accurate to the best of my knowledge. <br /> SIG OF T DATE / � ata• PHONE} r 425• <br /> NAME QF ApPPLICANT nt) 426• TITLE OF APPLICANT 427. <br /> STATE UST FACIL7V NUMBER(Agency use only) 428. 1998 UPGRADE CERTIFICATE NUMBER(Agency use only) 429. <br /> (See Data Element 1 above. <br /> UPCF Hwfwrc-a(1/99)-1/2 http://www.unidocs.org Rev.02/16/00 <br />