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IED PROGRAM CONSOLIDATED F010 <br />TANKS <br />UNDERGROUND STORAGE TANKS - FACILITY <br />YY <br />(One page per site) Page 1 of <br />TYPE OF ACTIONl. NEW PERMIT [13. 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 as FACILITY NAME or DBA - Doing Business As 3. <br />FACILITY <br />Ak-K i m -M-E $o)( 9 S -11 b9l <br />ID# <br />NEAREST CROSS STREET 401. <br />FACILITY OWNER TYPE ❑ 4. LOCAL AGENCY/DISTRICT* 402, <br />1 fj JBG 1 "( k4tj-{ ?q�C � p <br />KI. CORPORATION ❑ 5. COUNTY AGENCY* <br />❑ 2. INDIVIDUAL ❑ 6. STATE AGENCY* <br />BUSINESS 1. GAS STATION Lj 3. FAkM ❑ 5. COMMERCIAL 403. <br />TYPE ❑ 2. DISTRIBUTOR [:14. PROCESSOR ❑ 6. OTHER <br />[:13. 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 OWNERNAME 407. <br />')mss- I"`[��E 1_:2�ox <br />PHONE 408. <br />L7 <br />MAILING OR STREET ADDRESS 409 <br />CITY 410. <br />STATE 411• <br />ZIP ODE 412 <br />ELGia <br />k L <br />©i7-?-. <br />PROPERTY OWNER TYPE . CORPORATION 2. INDNIDUAL 4. LOCAL AGENCY / DISTRICT 6. STATE AGENCY 41 <br />❑ 3. PARTNERSHIP ❑ 5. COUNTY AGENCY ❑ 7. FEDERAL AGENCY <br />III. TANK OWNER INFORMATION <br />TANK OWNER NAME ala. PHONE <br />MAILING OR STREET ADDRESS <br />T aWE <br />CITY 417. STATE ale. ZIP CODE 419. <br />Lk <br />TANK OWNER TYPE 1. CORPORATION 2. INDNIDUAL 4. LOCAL AGENCY/DISTRICT ❑ 6. STATE AGENCY 420. <br />❑ 3. PARTNERSHIP ❑ 5. COUNTY AGENCY ❑ 7. FEDERAL AGENCY <br />IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br />TY TK H 44-q I G Call 916 322-9669 if questions arise 421. <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br />INDICATE METHOD(s) j 1. SELF-INSURED ❑ 4. SURETY BOND 17. STATE FUND ❑ 10. LOCAL GOVT MECHANISM 422 <br />Lj 2. GUARANTEE ❑ 5. LETTER OF CREDTT8. STATE FUND & CFO LETTER ❑ 99. OTHER: <br />-9. STATE FUND & CD <br />❑ 3. INSURANCE El 6. EXEMPTION <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 X3. 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 />24. PHONE <br />SIGNATURE ICA T DATE 4a2s. <br />NAME OF PLICAN p 'nt) 426. <br />TITLE OF APPLICANT ^� azz <br />=UST FACILITY NUMBER (Agency use only) 428. <br />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 />