Laserfiche WebLink
1cz- <br /> UNIFIED PROGRAM CONSOLIDATED FORM D\tc.. <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY NAFD > <br /> (one page per site) Page Ott- <br /> TWE OF ACTION U 1.NEW SITE PERMIT ❑3.RENEWAL PERMIT ❑5.CHANGE OF INFORMATION ❑ 7.PERMANENTLY CLOSED SITE <br /> (Check one item only) ❑4.AMENDED PERMIT specify change local use only. ❑ S.TANK REMOVED <br /> 6.TEMPORARY SITE CLOSURE 4a0 <br /> I. FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Same as FACILITY NAMam DBA-going Bou.Aa) 3 FACILITY ID# <br /> qQ10 <br /> CROSS STREET .;?,360 L•E 1 ht M}la 4^I FACILITY OWNER TYPE 4.LOCAL AGENCY/DISTRICT- <br /> NEAREST <br /> Co 2 W.CORPORATION ❑5.COUNTY AGENCY' <br /> BUSINESS 1.GAS STATION 3.FARM 5. COMMERCIAL ❑ 2.INDIVIDUAL ❑6.STATE AGENCY* <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR 9,6. OTHER 403 ❑ 3.PARTNERSHIP ❑7.FEDERAL AGENCY* 40z <br /> TOTAL NUMBER OF TANKS Is facility on Indian Reservation or 'If owner of UST is a public agency:time of supervisor of division,section or office which <br /> REMAINING AT SITE trustlands? operates the UST(This is the contact person for the tank records.) <br /> 2 ao4 Yes o say 406 <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME a0r PHONE 4(:8Q%c ('k- D *7401 <br /> MAILING OR STREET ADDRESS 449 <br /> PO Satz Q 21'✓I <br /> Ola STATE 411 ZIP CODE aiz <br /> CITY <br /> 5A l\ Gµ S&3 <br /> PROPERTY OWNER TYPE P5,1.CORPORATION Lj 2.INDIVIDUAL U 4.LOCAL AGENCY/DISTRICT 0 6.STATE AGENCY <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY 413 <br /> III.TANK OWNER INFORMATION <br /> KF�\t <br /> TAN` f4Vt"`lG D 4i4 PHONE O 4I5 <br /> LL <br /> MAIING OR STREET ADDRESS V/ll 416 <br /> rD � � awl_ 3toa� <br /> CITY 4n I STATE 418 ZIP CODE 419 <br /> TANK OWNER TYPE 01. .CORPORATION 2.INDIVIDUAL U 4.LOCAL AGENCY/DISTRICT U&STATEAGENCY 420 <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY TK H 44 Call 916 322-9669 if questions arise 421 <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s)1A1.SELF-INSURED ❑4.SURETY BOND ❑7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM <br /> ❑ .GUARANTEE ❑5.LETTER OF CREDIT ❑8.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 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 I or 2 is checked. ❑ 1.FACILITY PROPERTY OWNER ❑3.TANK OWNER 421 <br /> VII.APPLICANT SIGNATURE <br /> Certification-1 testify that the information provided heroin is true and accurate to the best of my knowledge. <br /> SIGN OF APP LICAN3n DATE 024 PHONE 425 <br /> LQDA 1�� 11-26-D2 25288 21x3 <br /> NAMg APPLICA (print) 426 TITLE OF APPLICANT 632 <br /> D£GNAG" C-k3 (,L <br /> STATE UST FACILITY NUMBER(Fix mczl use only) 4ze 1998 UPGRADE CERTIFICATE NUMBER(For local use oely) 029 <br /> UPCF(1/99 revised) 8 Formerly SWRCB Form A <br />