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UN IED PROGRAM CONSOLIDATED F ZM <br /> L <br /> I ] <br /> UNDERGROUND STORAGE TANKS - FACILITY TANKS <br /> (one Page Per site! <br /> TYPE OF ACTION r 1.NEW SITE PERMIT r 3.RENEWAL PERMIT r 5.CHANGE OF INFORMATION(S,,i dte�e- 1R 7.PERMANENTLY CLOS <br /> (Cnecx one item onN1 <br /> r 4 AMENDED PERMIT oca um only! r 8 7ANKREMOVEO <br /> r 6.TEMPORARY SITE CLOSURE <br /> I.FACILITY I SITE INFORMATION <br /> BUSINESS NME(SeorsinA3 1. 5. <br /> 1300 5;4e>P i Gr q <br /> NEAR STCROS TREET., 1 FFeACILITY OWNER TYPE <br /> `�✓Id0 a1V. CORPORATION r 4 LOCAL AGENCY/DISTRICT' <br /> .M/MSS TYPE r 1 GAS STATION r 3.FARM S COMMERCIAL r 2. INDIVIDUAL r 5. COUNTY AGENCY- <br /> r' Z DISTRIBUTOR r 4.PROCESSOR r 6.OTHER r 3. PARTNERSHIP r 6. STATE AGENCY' <br /> 403 r ]. FEDERALAGENCY- 402 <br /> TOTAL NUMBER OF TANKS Ia fapliN on/,Dian Resannii or 'it owner M UST is a Public agency:name of survor <br /> peisof <br /> REMAINING AT SITE truatlatw? dwiskm.secton or office whkM operates me UST. <br /> 404 Ts V a i O (This is Me coni Peron or low m <br /> aft reCs.) <br /> ori rye. 1xN0 405 406 <br /> TO'rHr 8 Ej r 0 F IVa Cr- i.PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME <br /> RDa0] P ONE 408 <br /> O �to1 a 484o3g <br /> MAILING OR STREET DDR S a09 <br /> D -LD <br /> CITY 410 STAT 411 ZIP CODE 412 <br /> OC.KTo <br /> PROPERTY OWNER TYPE . INDIVIDUAL r 4. LOCALAGENCY I DISTRICT r 6. STATEAGENCY 413 <br /> r 1. CORPORATION r 3. PARTNERSHIP r 5. COUNTYAGENCV r 7 FEDERALAGENCY <br /> 111.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> S � A-s T ow r.-P� <br /> MAILING OR STREET ADDRESS 416 <br /> CITY 41 STATE 418 ZIP CODE 419 <br /> TANK OWNER TYPE r 2. INDIVIDUAL r 4. LOCAL AGENCY/DISTRICT r 6. STATEAGENCV 420 <br /> r 1 CORPORATION [ 3. PARTNERSHIP r 5. COUNTYAGENCV r 7 FEDERALAGENCY <br /> TY(TK)HQ 4 1 4 - Call(916)322-9669 if questions arise KrA- 421 <br /> INDICATE METHOD(S) r 1. SELF-INSURED r 4. SURETY BOND 7. STATE FUND r 10. LOCAL GOVT MECHANISM <br /> r 2. GUARANTEE r 5. LETTER OF CREDIT r 8. STATE FUND&CFO LETTER r gis OTHER: <br /> r 3. INSURANCE r 6. EXEMPTION r 9. STATE FUND 8 CD 422 <br /> Chack are box to indicate whit,address should be used for legal notifications and mailing. r 1. FACILITY 2. PROPERTY OWNER r 3. TANK OWNER 423 <br /> Legal n efi s and mailings will be ant to the tank owner unlessbox 1 or eo. <br /> VII APPIJ(-_ANIT_5UrZNlATI1RF <br /> Cemfical cert inform n oro.taad herein is nue and acarate to the best of my kroaledge. <br /> SIGN; E L' N 7AVO 424 HON o 425 <br /> NAM OFMP C (Part) 11 426 TDLEOF;PPUCANT 427 <br /> Ow�.+� <br /> STATE UST FACILITY NUMBER(ForKcal useonly) 4211 1998 UPGRADE C UMBER(For lots use only) 429 <br />