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LI LFIED PROGRAM CONSOLIDATED FO <br /> TANKS V'L <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> / (One Page per site) Page_ <br /> TYPE OF ACTION ❑1.NEW PERMIT ❑3.RENEWAL PERMIT OF Ily M TION ❑7.PERMANENTLY CLOSED SITE '' <br /> (Check one item only) ❑4.AMENDED PERMIT(Specify change) tie G'w✓:'Q. ❑8.TANK REMOVED <br /> ❑6.TEMPORARY SITE CLOSURE <br /> BUSBIES NAME(Sasn;asF 1'I XM1l8orDBA-Miss Issmea As) s. 1 FACILITY <br /> Kr4ct <br /> ID"7H <br /> NEAREST CROSS STREET col. FAC f1'Y.OWNER TYPE ❑4.LOCAL AGENCY/DISTRICT- <br /> . <br /> �f.S+✓0 CORPORATION 0.5.COUNTY AGENCY' <br /> BUSINESS GAS STATION 3.FARM 5.COMMERCIAL 403. [12.INDIVIDUAL ❑6.STATE AGENCY' <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR ❑.6.OTHER 0.3.PARTNERSHIP [17.FEDERAL AGENCY" <br /> TOTAL NUMBER OF TANKS Ts facilityon hrdian Reservation 405. •If owner of UST is a public agency:nary of supervisor of division,section or 4c6. <br /> REMAINING AT SITE // or trust lands?? office which operates the UST. (This is the contact person for the tank records.) <br /> (i ❑Yea..6 <br /> PROPERTY OWNER NAME 407. PHONE 4oa. <br /> kw< Fat <br /> MAILING OR STREET ADDRESS <br /> 1/L'/ 01 l//laerrz j7 <br /> CITY 410. 1 STA'fI�n 411 ZIP CODE s- 41z <br /> SToc r-760 CA- <br /> PROPERTY OWNER TYPE._.. LCORPORATION LJ2.INDfVIDUAL U4.LOCAL AGENCY/DISTRICT U&STATEAGENCY 413. <br /> ❑.3.PARTNERSHIF ❑5_COUNTY AGENCY [17.FEDERAL AGENCY <br /> TANKOWNERNAME 414, 1 PHONE ``/�,, 415. <br /> MAILING OR STREET RESS 416. <br /> /7,0 (� O <br /> CITY 417. 1 STATE e/4 415. 1 ZIP CODE 419. <br /> TANK OWNER TYPE UrI.CORPORATION 2. NDWIDUAL ❑.4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 42a. <br /> CI 3.PARTNERSHIP 5.COUNTY AGENCY 7_FEDERAL AGENCY <br /> TyEMETHOD(s) <br /> Call 916 322-9669 if questions arise 421. <br /> IND ❑1.SELF-INSURED ❑4.SURETY BOND [y..,FrATE FUND ❑lo.LOCAL GOVT MECHANISM m <br /> ❑2.GUARANTEE ❑5.LETTER OF CREDIT [".STATE FUND A,CFO LETTER ❑99.OTHER: <br /> ❑3.INSURANCE ❑6.EXEMPTION ❑9.STATE FUND A,CD <br /> Check one box to indicate which address should be used for legal notifications and=it top. <br /> Legal notifications and nuilings will be sent m the rank owner unless box I or 2 is checked 1.FACILITY ❑2. PROPERTY OWNER ❑3.TANK OWNER 4n. <br /> Z` fACAI T STGNATU <br /> Certification: I certify flat the information provided hernia is nos and accurate to the best of my knowledge. <br /> SIGNATURE OF APPLICANT DATE PHONE <br /> 424 425. <br /> 1z�14 <br /> NAME OF APPLICANT(print) `` 426. TITLE OF APPLICANT 427 <br /> WJA9f1Z / �G � ���1 <br /> STATE UST FACILITY NUMBER(Agency a.e only) 428. 1998.UPGRADE CERTIFICATE NUMBER(Agcy ere ody) 42s. <br /> (See Dam Element 1,above. <br /> UPCF Hwfwrca(1/99)-12 http:/Avww.aaldoca.org Rev.02/16/00 <br />