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aff <br /> -WIFIFID PROGRAM CONSOLIDATED F"'- M <br /> -*ftw TANKS <br /> UNDERGROUND STORAGE TANKS - FACELITY <br /> (one page per site) Page of <br /> TYPE OF ACTION ❑ i.NEW SITE PERMIT 0 3.RENEWAL PERMIT 5.CHANGE OF INFORMATION L))I r 0 7 PERMANENTLY CL SITE <br /> (Check."nernonly) ❑4.AMENDED PERMIT specify change local the only_LLo B.TANK REMOVED <br /> 0 6TEMPORARY srrE CLOSURE aw <br /> L FACILITY/SITE INFORMATION JAN 1 6 ZOO I <br /> BUSINESS N7E IY NAME or DBA-Doug A" <br /> FACILITYID#M <br /> Covts <br /> NEAREST CROSS STREET FACILITY OWNER TYPE 0 4.LOCAL AGENCY/DISTRICTa <br /> -7(f ( A t ?5,9 06 )W 1.CORPORATION ❑5.COUNTY AGENCY' <br /> U 1.GAS Lj 5. COMMERCIAL <br /> BUSINESS rl-GrAS i MO FARM [1 2.INDIVIDUAL El 6.STATE AGENCY' <br /> TYPE [32.DISTRIBUTOR 0 4.PROCESSOR)K 6. OTHER 403 [] 3.PARTNERSHIP 0 7.FEDERAL AGENCY' 42 <br /> TOTAL NUMBER OF TANKS Is facility on Indian Reservation or Off owner of UST is a public agency:name ol'superiiisor of division,section or office which <br /> REMAINING AT SITE truatlands7 operates the UST(This is the contact person for the tanic rwwd&) <br /> 0 Yes DENO <br /> 11L PROPERTY OWNER INFORMATION C vte 4"V-e--45) <br /> PROPERTY OWNER NAME 07 3P1ONE <br /> covisol;(:�,ta Frei ti�-wo VVE- Y;2-7-5-- <br /> MAILING OR STREET ADDRESS 409 <br /> P- 0 . 60< 871,45-ID <br /> C410 STATE 411 ZIP CODE 412 <br /> %V�60u,vev- W4 99'687-16/ <br /> PROPERTY OWNER TYPE 1.CORPORATION [12.INDIVIDUAL Lj 4.LOCAL AGENCY DISTRICT Lj 6.STATE AGENCY <br /> El 3.PARTNERSHIP 0 5.COUNTY AGENCY 0 7.FEDERAL AGENCY 413 <br /> IIL TANK OWNER INFORMATION IAe d addVeC4) <br /> TANK OWNER NAME 414 PHONE 415 <br /> Awa 5 (354, D) <br /> C <br /> V_e ;5�� <br /> (fQ LA�S 0 11 <br /> MAILING OR STREET ADDRESS 416 <br /> OD- 0- 60X 97/5-/D <br /> v\ 417 STATE\,)/, 418 ZIP CODE 419 <br /> CITY 417 <br /> V 98087- <br /> TANK OWNER TYPE 1.CORPORATION LJ 2.INDIVIDUAL Lj 4. LOCAL AGENCY DISTRICT LJ 6,STATE AGENCY 420 <br /> 03.PARTNERSHIP El 5.COUNTY AGENCY C1 7. FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ44- 101 1 ! / 171691S- Call(916) 322-9669 if questions arise <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s)Al.SELF-INSURED [14.SURETY BOND [17.STATE FUND 0 10.LOCAL GOVT MECHANISM <br /> C3 2.GUARANTEE 0 5.LETTER OF CREDIT)?18.STATE FUND&CFO LETTER ❑ 99.OTHER: <br /> C3 3.INSURANCE [16.EXEMPTION 0 9.STATE FUND&CD 422 <br /> VL LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check we box to mdi.te which address should be mail for legal notifications and mailing. <br /> Legal notifications and mailimi will be sent w the tank owner unless bra,I or 2 LS checked. 0 1 FACILITY El 2. PROPERTY OWNER X3.TANK OWNER 423 <br /> VII.APPLICANT SIGNATURE <br /> Certification-I certify that the info anon provtdcd herem is true and accurate to the beat of my knowledge. PHONE <br /> SIGNATURE OF APPLIC DATE 424 425 <br /> TITLEJF APPLICANT Q7 <br /> NAME OF APPLICAN 426 L <br /> STATE UST FACILITY NUMBER(Fcfccai iscomy) 423 1998 UPGRADE CERTIFICATE NUMBER nor hicii cas,my) 429 <br /> UPCF(1/99 revised) 9 Formerly SWRCEI Form A <br /> L I A ?- <br /> bo/o J <br />