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• 1.aFIED PROG CONSOLIDATED FOIA <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILIoTYne ge per site) Page_of_ <br /> �5,CHANGE OF INFORMATION ❑7.PERMANENTLY CLOSED SITE <br /> TYPE OF ACTION ❑1.NEW PERMIT ❑3.RENEWAL PERMIT •�`e ❑S.TANK REMOVED <br /> (Check one item only) ❑4.AMENDED PERMIT (Specify chs ) <br /> 6.TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION <br /> BUSINESS NAME(samea FACIUTYNAMEor DBA-Doina Bmun As) 3, I <br /> FACILITY t <br /> WAO PLAZA at. FACILITY OWNER TYPE U 4.LOCAL AGENCY/DISTRICT' J0= <br /> NEAREST CROSS STREET v . 1 ❑1.CORPORATION C]5.COUNTY AGENCY' <br /> BUSHES L GAS STATION 3.FARM 5.COMMERCIAL 463. .}:INDIVIDUAL [16.STATE AGENCY' <br /> 3 PARTNERS <br /> C37.FEDERAL AGENCY" <br /> TYPE 2.DISTRIBUTOR E]4.PROCESSOR [16.OTHER 4os. '❑Lf owner of UST is a public agency: name of supervisor of division,section or Las <br /> TOTAL NUMBER OF TANKS +00- Is facility on Indian Reservation office which operates the UST. (This is the contact person for the tank records.) <br /> REMAINING AT SITE or trust lands? <br /> 5 ❑Yes KNO <br /> PROPERTY OWNER INFORMATION <br /> 407. PHONE +-s <br /> PROPERTY OWNERNAME pin p\ j"J: <br /> e 11 G <br /> s.s <br /> MAILING OR STREET ADDRE S <br /> 410. STATE 411. ZIP CODE 41' <br /> CITY <br /> +!3 <br /> PROPERTY OWNER TYPE I.CORPORATION 2.]NDIVIDUAL U 4.LOCAL AGENCY/ ATE-AGENCY <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY El <br /> El7.FEDERAL AGENCY <br /> III.TANK OWNER INFORMATION <br /> 414. 1 PHONE315 <br /> TANKOWNERNAME 4a _ t-( 66- 0'$.�3 <br /> ns <br /> MAILING OR STREET ADDRESS <br /> W �/� 41T STATE _ CO. ZIP CODE +la <br /> CITY ( � ' 9 <br /> TANK OWNER TYPE �-'� L CORPORATION 2.INDIVIDUAL 4.LOCAL AGENCY/DISTRICT 6.STATE AGENCY +.o <br /> 3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY TK HQ 44- Q Call 916 322-9669 if uestions arise =1 <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(;) ❑1.SELF-INSURED ❑4.SURETY BOND 7.STATE FUND E]10.LOCAL GOVT MECHANISM +„ <br /> 0 2.GUARANTEE 5. STATE FUND <br /> d 3.INSURANCE ❑6.E)MMPTILETTER OOF CREDIT O 9.STATE FUND&CD LETTER ❑99.OTHER: <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Cheek one box m indicate which;darts;should be Bed for kgal notifications and mailing. +�_ <br /> Legal notifications and mailings will be sent to the tank owner unless box I or 2 is checked. ❑ 1.FACILITY C]2. PROPERTY OWNER 3.TANK OWNER <br /> VII.APPLICANT SIGNATURE <br /> Certification: I certify that the infornation provided herein is true and accurate W the best ofmy knowledge. 4x4. PHON <br /> _5-2_ <br /> + <br /> SIG U OF APPL NT ) knowledge- <br /> DATE L4,-AAA <br /> Q3 M <br /> ITLE OF <br /> N M A LI t 4� T '7-APPLICANT <br /> MA LKIN <br /> STATE UST FACILITY NUMBER(Agent me only) alt. 1998 UPGRADE CERTIFICATE NUMBER(Agesey B<wry) <br /> (See Data Element 1,above. <br /> UPCF Hwfwrc-a(1/99)-1/2 http://www.unido"xrg Rev.02/16M <br />