Laserfiche WebLink
UI IFIED PROGRAM CONSOLIDATED FO <br /> TANKS $1XIV <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (One page per site) Page_of_ <br /> TYPE OF ACTION ❑1.NEW PERMIT ❑3.RENEWAL PERMIT OWCHANG4 OF INFORMATION ❑7.PERMANENTLY CLOSED SITE 400' <br /> (Check one item only) ❑4.AMENDED PERMIT(Specify change) JVttd c :-_/Z ❑8.TANK REMOVED <br /> ❑6.TEMPORARY SITE CLOSURE <br /> L FACILITY/SITE INFORMATION <br /> BUSINES NAME(sarrcrPwcn3TV NAMe or DBA Dom,land aAs) 3 FACILITY ° <br /> I <br /> ,, -- <br /> NEAREST CROSS STREET 401. FAC I'L Y OWNER TYPE ❑4.LOCAL AGENCY/DISTRICT' - <br /> r,f�sIC3 CORPORATION ❑5.COUNTY AGENCY' <br /> BUSINESS .GAS STATION U 3.FARM m 5.COMMERCIAL 4UA ❑2.INDIVIDUAL ❑6.STATE AGENCY* <br /> TYPE ❑2.DISTRIBUTOR ❑.4..PROCESSOR ❑6.OTHER ❑3.PARTNERSHIP ❑7.FEDERAL AGENCY* <br /> TOTAL NUMBER OF TANKS Is facility on Indian Reservation 4015. •If owner of UST is a public agency:name of supervisor of division,section or 4,6 <br /> REMAINING AT SITE /� or trust lands9 office which operates the UST. (This is the contact person for the tank records.) <br /> (i ❑Yes ® <br /> wF 'L'-Y_OWNER INFORMATION <br /> PROPERTY OWNER NAME /� "I I PHONE 408. <br /> MAILING OR STREET ADDRESS <br /> 1/V W 409_ <br /> CITY L ato.WSTA 411. ZIP CODE // 412. <br /> STOC.r?O.) A I <br /> PROPERTY OWNER TYPE 1.CORPORATION 0 2.INDIVIDUAL ❑4.LOCAL.AGENCY/DISTRICT 6.STATE AGENCY 413 <br /> [-13.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> -' Ili.TANK OWNER INFORMATION <br /> TANK OWNER NAME414. PHONE //// 415. <br /> i,LbS Ids ��1f�OQ,st T <br /> MAILING OR STREET ADDRESS 416 <br /> CITY / 417. STATE418. ZIT CODE ash ` 419. <br /> A <br /> TANK OWNER TYPE Ljrl.CORPORATION [12.INDIVIDUAL ❑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)HQ 44Call 916 322-9669 if questions arse 421. <br /> V.PETR LEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ❑ 1.SELF-INSURED ❑4.SURETY BOND [,.f TATE FUND ❑10.LOCAL GOVT MECHANISM 422 <br /> [12.GUARANTEE [15.LETTER OF CREDIT [VS.STATE FUND&CFO LETTER ❑99.OTHER: <br /> ❑3.INSURANCE [16.EXEMPTION ❑9.STATE FUND&CD <br /> VL 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 l or 2 is checked. QUI.FACILITY 02. 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 /> SIGNATURE OF APPLICANT - DATE 424. PHONE 425. <br /> NAME OF APPLICANT(print) 426_ TITLE OF APPLICANT 427, <br /> STATE UST FACILITY NUMBER(Aee y nm omy) 428. 1998 UPGRADE CERTIFICATE NUMBER(Agency use owy) az9 <br /> [STATE <br /> Element 1,above. <br /> UPCF Hwfwrc-a(I/99)-1/2 http://www.unidoes.org Rev.02/16/00 <br />