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nook <br />D Wo % <br />UNIFIED PROGRAMOLIDATED FORM <br />TANKS <br />UNDERGROUND -,STORAGE TANKS - FACILITY �1 <br />(One page per site) Page 1 of <br />TYPE OF ACTION 1. NEW PERMIT ❑ 3. RENEWAL PERMIT ❑ 5. CHANGE OF INFORMATION ❑ 7. PERMANENTLY CLOSED SITE 400. <br />(Check one item only) ❑ 4. AMENDED PERMIT (Specify change) ❑ 8. TANK REMOVED <br />❑ 6. TEMPORARY SITE CLOSURE <br />I. FACILITY/SITE INFORMATION <br />BUSINESS NAME (sa-t w FACILITY NAMEJor oBA- Do ng Busi�xss As> 3 � 1. <br />r Il1,c �r �- a <br />AREST CROSS STREET 4o1.rn <br />CILITY OWNER TYPE 4. LOCAL AGENCY/DISTRICT* aoz. <br />f /,' ' . 1. CORPORATION ❑ 5. COUNTY AGENCY* <br />BUSINESS [11. GAS STATION ❑ 3. FARM [15. COMMERCIAL 403- 2. INDIVIDUAL 6. STATE AGENCY* <br />TYPE [:12. DISTRIBUTOR ❑ 4. PROCESSOR V 6. OTHER [13. PARTNERSHIP ❑ 7. FEDERAL AGENCY* <br />�* If owner of UST s a public agency: name of supervisor of division, section or 406. <br />TOTAL NUMBER TANKS a� Is facility on Indian Reservation 405. ffice which operates the UST. (Th s is the contact person for the tank records.) <br />REMAINING AT SITE or trust lands? o _ <br />❑ Yes No 10.4 <br />II. PROPERTY OWNER INFORMATION <br />P OP TY OWNER NAME 407- PHONE 408 <br />�� o � <br />409. <br />MAILING OR S REETABDRESS <br />t 410. STATE all. ZIP CODE 412. <br />CITY� 5- � <br />5cc W CL413. <br />PROPERTY OWNER TYPE 1. CORPORATION 2. INDIVIDUAL 4. LOCAL AGENCY / DISTRICT 6. STATE AGENCY <br />❑ 3. PARTNERSHIP ❑ 5. COUNTY AGENCY ❑ 7. FEDERAL AGENCY <br />111.TANK' OWNER INFORMATION <br />TANK OWNER NAME 414. PHO ZO <br />e N' <br />416. <br />MAILING OR S T ADD SS <br />CITY 417. 1 STATE,418. ZIP CODE 419. <br />xtt TANK OWNER TYPE 1. CORPORATION 2. INDIVIDUAL ❑ 4. LOCAL AGENCY/DISTRICT 6. STATE AGENCY 420. <br />❑ 3. PARTNERSHIP ❑ 5. COUNTY AGENCY ❑ 7. FEDERAL AGENCY <br />IV. BOARD OY EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br />TY TK HQ 44 Call 916 322-9669 if questions arise 421. <br />V. PETROLEUM LIST FINANCIAL RESPONSIBILITY <br />INDICATE METHOD(s) ❑ 1. SELF-INSURED ❑ 4. SURETY BOND ❑ 7. STATE FUND Q 10. LOCAL GOVT MECHANISM 422- <br />❑ 2. 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. 423 <br />Legal notifications and mailings will be sent to the tank owner unless box 1 or 2 s checked.1. FACILITY ❑ 2. PROPERTY OWNER ❑ 3. TANK OWNER <br />VII. APPLICANT SIGNATURE <br />Certification: I certify that the informal provided herein is true and accurate to the best of my knowledge. <br />SIG OF T / <br />DATE aza. PHO azs. <br />l/ z�Zt <br />NAME F PLICANT nt) 426- TITLE OF APPLICANT az7. <br />STATE UST FAC!NUMBER (A ency use only) 428- 1 1998 UPGRADE CERTIFICATE NUMBER (Agency use only) 429. <br />(See Data Element 1/above. <br />UPCF Hwfwrc-a (1/99) -1/2 http://www.unidoCLotg Rev. 02/16/00 <br />