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NIFIED PROGRAM CONSOLIDATED FORT PR#: <br /> FAC N: <br /> UNDERGROUND STORAGE TANKS -FACILITY L� <br /> (one page per site)e1q D3 <br /> TYPE OF ACTION ❑ L NEW SITE PERMIT ❑ 3.RENEWAL PERMIT E] 5.CHANGE OF INFORMATION ❑ 7.PERMANENTLY CLOSED SITE p�L <br /> (Check one item only) <br /> ❑ 4.AMENDED PERMIT RS.TANK REM <br /> 116.TEMPORARY SITE CLOSURE <br /> I.FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Bwe.FACartYNAbs aDRA-Mass nusiasAr) s FACTUM) IT <br /> PR IDN <br /> NEARESYT CnROSS STREE�T/A ' �1 ACB.I7Y OWNER TYPE <br /> C-G Z'Z& e7- WI� ao1 ❑ I.CORPORATION ❑4.COUNTY AGEAL Y/DISTRiC7' <br /> BUSINESS ❑ 5.COUNTY AGINCY' <br /> TYPE ❑ 1.GAS STATION ❑3.FARM ❑ 5.COMMERCIAL ❑2.AIDNmUAL <br /> ❑2.DISTRIBUTOR ❑ 4.PROCESSOR 3.PARTNERSHIP ❑ 6.STATE AGENCY- <br /> E] 4al ❑ ❑ 7.FEDERAL AGENCY" 402 <br /> TOTAI.NUMEER OF TANKS Is facility on Lldian Reservation or .Yawner of UST isapublic agency:name of supervisor ofdivision,section or office which operate <br /> REMAINING AT SITE trustlands? <br /> the UST(This is the contact Person for the tank records.) <br /> 2 40 ❑Yes N-No 405 <br /> 4% <br /> II.PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407P ONE <br /> r f oca on/ toy 7- peclo 401 <br /> MAn.ING OR STREET ADDRESS <br /> 0/t 409 <br /> CRY ,to STATE 011 ZIP 0 <br /> 7OP� nz <br /> To �/ C <br /> PROPERTY OWNER TYPE ❑ 1 XORPORATION ❑ 2.INDIVIDUAL ❑ 4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY <br /> ❑3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY 413 <br /> IU.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE <br /> r --? 7-064 7 `15 <br /> MAILING OR STREET ADDRES 209 37 -�b'YO <br /> E <br /> 416 D o.r A '0o T <br /> CITY STATE <br /> 417 418 1 1CODE419 <br /> Too /-f 7-a N C z 0 -/ <br /> TANK OWNER TYPE - <br /> El CORPORATION ❑ 2.INDIVIDUAL 114.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY 420 <br /> ❑ 3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- Call(916)322-9669 if questions arise 421 <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ❑ 1.SELF-INSURED ❑4.SURETY BOND ❑ 7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM <br /> ❑2.GUARANTEE ❑5.LETTER OF CREDIT ❑ 8.STATE FUND&CFO LETTER ❑99.OTHER <br /> ❑3.INSURANCE ❑ 6.EXEMPTION ❑ 9.STATE FUND&CD 41z <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one box to indicate which address should be used for legal unifications and mailing. ❑ I.FACILITY 2.PROPERTY OWNER ❑3.TANK OWNER 423 <br /> Legal notifications and mailing will be sent to the tank ower unless box I or 2 is checked. <br /> VH.APPLICANT SIGNATURE <br /> Certification-1 certify that the information provided berein is true and accurate to the best ofmy knowledge. <br /> SIGNA F PLI DATE 430 PHONE ) 425 <br /> N OF APPLICANT(print) 426 TITLE OF APPLICANT LICA g/z 6�/�6 O/ <br /> 427 <br /> 8P T �issp Ne oft o N11AA111 GP <br /> STATE UST FACR.ITY NUMBER(pe local ucrady) 428 1998 UPGRADE CERTIFICATE NUMBER(Forkad me auy) 429 <br /> Is 1998 Compliant? <br /> UPCF(1/99 revised) <br />