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U2':'1ED PROGRAM CONSOLIDATED FOIA <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page per site) Page_of <br /> TYPE OF ACTION ❑ 1.NEW SITE PERMIT ❑3.RENEWAL PERMIT ❑5.CHANGE OF INFORMATION ❑ ].PERMANENTLY CLOSED SIT <br /> (Check one nem only) ❑4.AMENDED PERMIT specify change local use only ❑ 8.TANK REMOVED <br /> ❑6.TEMPORARY SITE CLOSURE 400 �u <br /> O <br /> I. FACILITY/ SITE INFORMATION <br /> BUSINESS NAME(s. uFA NwhtE«new-ow.gg.aa_m) 3 FACILITYIDNRFI d <br /> to O tI F I A I l ,5-' <br /> NEARESTCROSS S l nw OatILITY OWNER TYPE 4.LOCAL AGENCY/DISTRICT- <br /> 551.CORPORATION [15.COUNTY AGENCY' <br /> BUSINESS 1.GAS STATION U 3.FARM U 5. COMMERCIAL ❑ 2.INDIVIDUAL ❑6.STATE AGENCY' <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR❑6. OTHER 403 ❑ 3.PARTNERSHIP ❑7.FEDERAL AGENCY- wz <br /> TOTAL NUMBER OF TANKS Is facility on Indian Reservation or -If owner of UST is a public agency:rams of supervisor of divisioq section or office which <br /> REMAINING AT SITE trogdan 7 operates the UST(This i the cornact person for the tank records.) <br /> ea ❑ Yes No 405 406 <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY O R 407 -ONE 4oa <br /> 20 <br /> MAILING OR TREEf ADDRESS 409 <br /> 0 6OK (e 03S <br /> CITY 2 % 410 STATE etc ZIP CODE 9 e�-Z D 412 <br /> S V <br /> PROPERTY OWNER TYPE 1.CORPORATION 2.INDIVIDUAL U 4.LOCAL AGENCY/DISTRICT U 6.STATE AGENCY <br /> [13.PARTNERSHIP [15.COUNTY AGENCY ❑7.FEDERAL AGENCY 413 <br /> M. TANK OWNER INFORMATION <br /> TANK OWNER NAME leC ,\GJ 414 P /Y O 415 <br /> MAILING ORS DIf,);.SIISU 416 <br /> C//1 � <br /> CITYm STATE 4,s ZIP CODE u9 <br /> /4 ��✓r�t v 7 Tz - <br /> TANK OWNER TYPE Dr.CORPORATION U 2.INDIVIDUAL U 4.LOCAL AGENCY/DISTRICT Lj 6.STATE AGENCY 420 <br /> El 3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY TK HQ 44- O U S D 1 L I Call 916 322-9669 if questions arise 421 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) 1b.SELF-INSURED ❑4.SURETY BOND ❑7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM <br /> [12.GUARANTEE [:15.LETTER OF CREDIT ❑S.STATE FUND&CFO LETTER ❑ 99.OTHER: <br /> ❑3.INSURANCE ❑6.EXEMPTION ❑9.STATE FUND&CD 422 <br /> VI. LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one box tc isdiram which address should be used for legal notifications and mailing. <br /> Legal notifications and mailings will be sent to the tank owner urdess box 1 or 2 is checked. ❑ ].FACILITY ❑2. PROPERTY OWNER b.TANK OWNER 423 <br /> VII. APPLICANT SIGNATURE <br /> Certification-I ify Pt the information provided herein is true W ac unu to the best of my knowledge. <br /> SIGNATLNF PLICANT DATE 420 1 PHONE 425 <br /> a 7 ?D - U <br /> NAME OF LICANT(print) /J 426 TITLE OF APPLICANT 427 <br /> 46f-r-2- 45;v. dpvollln4e <br /> STATE UST FACILITY NUMBER(For m1..any) els 1996 UPGRADE CERTIFICATE NUMBER(Far bul u.c any) 429 <br /> UPCF(1/99 revised) 8 Formerly SWRCB Form A <br />