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Py M)/io1)I- <br />I TIED PROGRA TANKS OLIDATED FO ,,� W I I I I �f rp <br />1 <br />UNDERGROUND STORAGE TANKS - FACILITY 0-0-06 h� <br />(One page per site) Page I of -7 <br />TYPE OF ACTIONI. 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 (Same ss FACILITY NAME or DBA - Doing Business As) 3. <br />FACILITY <br />.SACK 1 µ TIA-E ADX I l b9l <br />ID"17 <br />1. <br />NEAREST CROSS STREET 401. <br />F CILITY OWNER TYPE ❑ 4. LOCAL AGENCY/DISTRICT* 402 <br />l O $ 'at 4t -t-( p� �pcJ�TO is <br />Q!Ll. CORPORATION ❑ 5. COUNTY AGENCY* <br />❑ 2. INDIVIDUAL ❑ 6. STATE AGENCY* <br />BUSINESS al. GAS STATION ❑ 3. FARM ❑ 5. COMMERCIAL 403. <br />TYPE ❑ 2. DISTRIBUTOR [14. PROCESSOR [16. OTHER <br />❑3. PARTNERSHIP ❑ 7. FEDERAL AGENCY* <br />TOTAL NUMBER OF TANKS 404. <br />Is facility on Indian Reservation 405, <br />*If owner of UST is a public agency: name of supervisor of division, section or 406. <br />REMAINING AT SITE <br />or trust lands? <br />office which operates the UST. (This is the contact person for the tank records.) <br />2, <br />❑ Yes KNo <br />II. PROPERTY OWNER INFORMATION <br />PROPERTY OWNER NAME 407. <br />PHONE 408. <br />J 4C -Y- t " `r4k.-e <br />MAILING OR STREET ADDRESS 409. <br />CITY 410. <br />STATE 411. <br />ZIP ODE 412. <br />\ L <br />c) z <br />PROPERTY OWNER TYPE . CORPORATION ❑ 2. INDIVIDUAL ❑ 4. LOCAL AGENCY / DISTRICT ❑ 6. STATE AGENCY 413. <br />❑ 3. PARTNERSHIP ❑ 5. COUNTY AGENCY ❑ 7. FEDERAL AGENCY <br />III. TANK OWNER INFORMATION <br />TANK OWNER NAME 414. <br />PHONE 415. <br />MAILING OR STREET ADDRESS 416. <br />T 1s c-� TD0i0E <br />CITY an. <br />STATE als. <br />ZIP CODE 419. <br />C-LE,i u 1 <br />k L <br />GO 123 <br />TANK OWNER TYPE 1. CORPORATION ❑ 2. INDIVIDUAL ❑ 4. LOCAL AGENCY/DISTRICT ❑ 6. STATE AGENCY azo. <br />[:13. PARTNERSHIP [15. COUNTY AGENCY [17. FEDERAL AGENCY <br />IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br />TY (TK) 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 17. STATE FUND ❑ 10. LOCAL GOVT MECHANISM 422 <br />2. GUARANTEE ❑ 5. LETTER OF CREDIT hL��J1 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 1 or 2 is checked. ❑ 1. FACILITY [:12. PROPERTY OWNER )K3. 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 />SIGNATURE P ICANT <br />DATE 424. <br />S i0lo 6 <br />PHONE 425. <br />4.60-233-3995 <br />NAME OF A PLICAN nt) 426. <br />TITLE OF APPLICANT 427. <br />Dc, W <br />� -Ff�i- I" -RW �3c'K <br />STATE UST FACILITY NUMBER (Agency use only) 428. <br />1998 UPGRADE CERTIFICATE NUMBER (Agency use only) 429. <br />(See Data Element 1, above.1 <br />UPCF Hwfwrc-a (1/99) -1/2 http://www.unidocs.org Rev. 02/16/00 <br />