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� `L o1 Ipz <br /> IVIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY ]] <br /> (one page per site) Page oto_ <br /> TYPE OF ACTION ❑ 1.NEW SITE PERMIT 0 3.RENEWAL PERMIT ❑5.CHANGE OF INFORMATION ❑ 7TERMANENTLY CLOSED SITE <br /> (Check one item only) ❑4.AMENDED PERMIT specify change local use only ❑ 8.TANK REMOVED <br /> 41 TEMPORARY SITE CLOSURE 40D <br /> I. FACILITY/SITE INFORMATION <br /> BUSINESS NAME(same.0 FACILITYNA Em DBA-Dena,Busi. .A,) 3 FACILITYID# <br /> y0 8 <br /> NEAREST CROSS STREET 4360 t:. E�qht M11 It 401 FACILITY OWNER TYPE Lj 4.LOCAL AGENCY/DISTRICT' <br /> CV 1.G �1.CORPORATION ❑5.COUNTY AGENCY- <br /> BUSINESS AS STATION 5. COMMERCIAL 3.FARM or ❑ 2.INDIVIDUAL ❑6.STATE AGENCY' <br /> ❑ 9 <br /> TYPE 2.DISTRIBUTOR ❑4.PROCESSOR ,6. OTHER 4a3 ❑ 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 name 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 /> 2 404 Yes o 405 406 <br /> IL PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 401 PHONE 408 <br /> ?Kkckc 61L.L. o ?4o I <br /> MAILING OR STREET ADDRESS <br /> LI400 <br /> TD 'Olm Q Rt11 <br /> CITY 010 1 STATE 411 ZIP CODE 412S R n GA S&3 <br /> PROPERTY OWNER TYPE I.CORPORATION Lj 2.INDIVIDUAL Lj 4.LOCAL AGENCY/DISTRICT Lj 6.STATE AGENCY <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY 413 <br /> III.TANK OWNER INFORMATION <br /> TANKOWN NAME 414 PHONE 415 <br /> Tr1 BLL 12 qol '7D <br /> MAI ING OR STREET ADDRESS 416 <br /> <D g Rr(_ 340017 <br /> CITY417 STATE 418 ZIP CODE 419 <br /> S n rlor <br /> Ra \ C� glt5S3 <br /> TANK OWNER TYPE W4,CORPORATION LJ2.fNDIVIDUAL U 4.LOCAL AGENCY/DISTRICT U 6.STATE AGENCY 420 <br /> [13.PARTNERSHIP [15.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY TK HQ 44 1 01 S I 1 1 4 1 1 1 L4 Call 916 322-9669 if questions arise 421 <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) L SELF-INSURED ❑4.SURETY BOND [17.STATE FUND ❑ 10.LOCAL GOVT MECHANISM <br /> '0'2.GUARANTEE [:15.LETTER OF CREDIT [18.STATE FUND&CFO LETTER ❑ 99.OTHER: <br /> ❑3.INSURANCE ❑6.EXEMPTION [19.STATE FUND&CD 4zz <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 1 m 2 is checked. ❑ 1.FACILITY PROPERTY OWNER ❑3.TANK OWNER 423 <br /> VII.APPLICANT SIGNATURE <br /> Certification-1 certify that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGN RE OF APPLICANTDATE 624 1 PHONE 425 <br /> L 2 Fba I L7 f 1-26-02 25'288 2143 <br /> 4n <br /> NA OF APPLICA (print) <br /> 426 TITLE OF APPLICANT <br /> JRl 0&-,06" 6`An- F((--14L� <br /> STATE UST FACILITY NUMBER n c k,c.l a.e ualy) 038 1998 UPGRADE CERTIFICATE NUMBER(Fa last u.e aly) 429 <br /> UPCF(1/99 revised) 9 Formerly SWRCB Form A <br />