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tFIED PROGRAM CONSOLIDATED FOR <br /> �1. TANKS *400 a <br /> UNDERGROUND STORAGE TANKS - FACILITY lIL <br /> (One page per site) Page_of <br /> TYPE OF ACTION )(I.NEW PERMIT ❑3.RENEWAL PERMIT [15.CHANGE OF INFORMATION [17.PERMANENTLY CLOSED SI ' 4W <br /> (Check one item only) ❑4.AMENDED PERMIT (Specify change) [18.TANK REMOVED 111///It/]"'"`j <br /> ❑6.TEMPORARY SITE CLOSURE D Q I n 9 D' a <br /> I. FACILITY/SITE INFORMATION /` J O <br /> B (NESS NAME( as FACILITY NAME or DBA-MingnosinessAs) 3. FACILITY <br /> a YCf ID# <br /> 'Pit /4 <br /> REST SSS REET -q` 401. FACILITY OWNER TYPE ❑4.LOCAL AGENCY/DISTRICT- <br /> Ir <br /> GENCY/DISTRICT• 402. <br /> 3 Bb I 1 c ❑ 1.CORPORATION ❑5.COUNTY AGENCY• <br /> BUSINESS 1.GAS STATION Lj 3.FARM ❑5.COMMERCIAL ❑2.INDIVIDUAL ❑6.STATE AGENCY" <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR ❑6.OTHER 5�3.PARTNERSHIP ❑7.FEDERAL AGENCY' <br /> TOTAL NUMBER OF TANKS - Is facility on Indian Reservation 405. *If owner of UST is a public agency: name of supervisor of division, section or 406_ <br /> REMAINING AT T or trust lands? office which operates the UST. (This is the contact person for the tank records.) <br /> ❑Yes DdNo <br /> IL PROPERTY OWNER INFORMATION <br /> PRg ERTYOWNE AME 401, ONE 408. <br /> / t- 6`% °I -int 9 (1 <br /> M ILING O TRE T ADDRESS 409, <br /> 0 1 T, t, <br /> CITY 0101STATE 411. ZIP CODE 412. <br /> (i A (lj <br /> PROPERTY OWNER TYPE Lj 1.CORPORATION Lj 2.INDIVIDUAL Ll 4.LOCAL AGENCY/DISTRICT L16.STATEAGENCY 413_ <br /> PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> III.TANK OWNER INFORMATION <br /> TAN WNERNAME 414, P NE 415. <br /> vle - tly <br /> MAILING OR RTREET ADDRESS 416. <br /> 4 <br /> CI 417. STATE 413. ZIP CODE 419. <br /> TANK OWNER TYPE 1.CORPORATION 2.INDIVIDUAL 4.LOCAL AGENCY/DISTRICT 7 6.STATE AGENCY azo. <br /> W3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY TK HQ 44- 1 1 1 1 1 1 1 Call 916 322-9669 if questions arise 421. <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ❑ 1.SELF-INSURED [14.SURETY BOND ❑7.STATE FUND [110.LOCAL GOVT MECHANISM 422 <br /> ❑2.GUARANTEE [15.LETTER OF CREDIT [18.STATE FUND&CFO LETTER [199.OTHER: <br /> ❑3.INSURANCE [16.EXEMPTION ❑9.STATE FUND&CD <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one hos m indicate which address should be used for legal notifications and mailing. <br /> Legal notifications and mailings will be sent m the lank owner unless box I or 2 is checked. ❑ L FACILITY X 2. PROPERTY OWNER [13.TANK OWNER 421. <br /> VII.APPLICANT SIGNATURE <br /> Certification: 1 certify that the infornation provided herein is true and accurate to the best of my knowledge. <br /> SIGNATURE OF APPLICANT DATE 424. PHONE 425. <br /> NAME OF APPLICANT(print) 42a TITLE OF APPLICANT 427 <br /> STATE UST FACILITY NUMBER(Agency use only) 42a 1998 UPGRADE CERTIFICATE NUMBER(Agency we only) 429. <br /> (See Data Element 1,above. <br /> UPCF Hwfwrc-a(1/99)-1/2 btip:H/ w.unickamorg Rev.02/16/00 <br />