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MD PROGRAM CONSOLIDATED F,VI <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILIOTYge per site) Pa52h- <br /> TYPE <br /> OF ACTION 1.NEW PERMIT ❑7.RENEWAL PERMIT ❑5.CHANGE OF INFORMATION [17.PERMANENTLY CLOSED SITE °on <br /> ❑4.AMENDED PERMIT (Spenfy change) ❑a.TANK REMOVED �\D <br /> (Check on item only) ❑6.TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION Vy <br /> BUSINESSNAME(SanenFACILITY NAMB or DBA-Dong Busimus Ar) 5. FACILITY O a I i <br /> 5, 100L <br /> NEA T CROSS STREET v FACILITY OWNER TYPE 4.LOCAL AGENCY/DISIRICT• w= <br /> �+�+ / C CORPORATION ❑5.COUNTY AGENCY* <br /> B SINESS L GAS STATION 3.FARM 5.COMMERCLAL 40s 2.INDIVIDUAL ❑6.STATE AGENCY* <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR.OTHER [13.PARTNERSHIP ❑7.FEDERAL AGENCY* <br /> 405. •If owner of UST is a public agency:name of supervisor of division,ration or 406. <br /> TOTAL NUMBER OF TANKS d04 Is facility on Indian Reservation office which operates the UST. is is the contact person for the tank mods.) <br /> REM A AT SITE or trust lands? p <br /> ❑Ye p D <br /> IL PROPERTY OWNER INFORMATION <br /> PROPERTYOWNER NAME 601 PHONE 40a <br /> P 0 83 `f0 <br /> M I IN R STREET ADDRESS 409. <br /> Tit v Sii Gf�/�fiL L c� <br /> CIT 10 STATE 411 ZIP COD�� �� of=. <br /> PROPERTY OWNER (PE ,$^CURPUia-T-lON--rT2.lNDrVIDUAL U 4.LOCAL AGENCY/DISTRICT Lj 6.STATE AGENCY 413. <br /> ❑3.PARTNERSHIP ❑S.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> M.TANK OWNER INFORMATION <br /> TANKOWNERNAME 414. PHONE ns. <br /> MAILING 2&STREET ADRWS ) 416. <br /> CITY� L 417. STATE _ 41a. ZIP CODE /7 ! 4M <br /> TANKOWNERTYPE .CORPORATION 2.INDIVIDUAL U 44..•LOCAL AGENCY/DISTRICT Lj 6.STATE AGENCY ao. <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY [17.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 ❑4.SURETY BOND [17.STATE FUND ❑t0.LOCAL GOVT MECHU`ls.%, 42z <br /> 02.GUARANTEE [j5.LETTER OF CREDIT ❑S.STATE FUND&CFO LETTER ❑99.OTHER: <br /> ,A a.p.lINSURANCE ❑6.EXEMPTION ❑9.STATE FUND&CD <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Chock one box to indicate which address should be used for legal notifications and®ling. <br /> Legal notifications and mailings will be sent to the tank owner unless box 1 or 2 is checked ❑ 1.FACILITY ❑2. PROPERTY OWNER �;<3.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 /> NT DATEo3 / a Qc430. PHONE gJZ <br /> 425.GA o 3 <br /> NAME OF APPLICAN rint) 426. <br /> TITLE OF APPLICANT 037. <br /> tA 0*'�E13 ^9-GAN13 lar 5s.�t-i`a_L- Cr <br /> STATE UST FACILITY NUMBER(Agaxey usa only) 429. 1998 UPGRADE CERTIFICATE NUMBER(Ageooy ora onry) 429. <br /> (See Data Element 1.above. <br /> UPCF Hwfwrc-x(1/99)-1/2 http://was .unidocs.org Rev.02/16/00 <br />