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UNDERGROUND STORAGE TANKS - FACILITY RECEIVEQ <br /> (One page per site) Page_o <br /> TYPE OF ACTION [11.NEW PERMIT ❑3.RENEWAL PERMIT 5.CHANGE OF INFORMATION ❑7.P Y"Ap400. <br /> (Check one item only) [14.AMENDED PERMIT (Spec' change) ❑8.TANK MgUAU[N COUNTY <br /> ❑6.TEMPOIL4RY SITE CLOSURE OFFICE OF EMERGENCY SEWCES <br /> I. FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Sameas FACILr NAMEar DBA-Doing Rumness As7 3. FACILITY <br /> ID11 <br /> NEAREST CRO STREET anl. FACILITY OWNER TYPE ❑4.LOCAL AGENCY/DISTRICT 402. <br /> f+ %1.CORPO TION ❑5.COUNTY AGENCY' <br /> BUSINESS^ 1.GAS STATION ❑3.FARM E]5.COMMERCLA.L 403. E]2.INDIVID AL ❑6.STATE AGENCY' <br /> TYPE ❑2.DISTRIBUTOR [14.PROCESSOR ❑6.OTHER ❑3.PARTNERSHIP ❑7.FEDERAL AGENCY* <br /> TOTAL NUMBER OF TANKS 404. Is facility on Indian Reservation 405. «If owner of UST is a public agency:name of supervisor of division,section m 406. <br /> REMAINING AT SITE or trust lands? office which operates the UST. (This is the contact person for the tank records.) <br /> ❑Yes o <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTYOWNERNAME 407, PHONE 409 <br /> // r D� <br /> MAILING OR STREET ADDRESS 409. <br /> ua STATE 411. ZIP CODE 411 <br /> crrY�C�7TLc" <br /> PROPERTY OWNER TYPE 1.CORPORATION LJ2ANDIVIDUAL U 4.LOCAL AGENCY/DISTRICT Lj 6.STATE AGENCY 411 <br /> ❑3.PARTNERSHIP [:15.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> III.TANK OWNER INFORMATION <br /> TANKOWWN-ERNAME / ala. PHONE 415. <br /> MAILING OR STREET ADDRESS 416' <br /> CITY 417. STATE ue. ZIP CODE 419. <br /> "�9TlZ,�_ Ll/f! �/ <br /> TANK OWNER TYPE 1.CORPORATION ❑2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT 0 6. TATE AGENCY 420. <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY [17.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-MSURED ❑4.SURETY BOND ❑7.STATE FUND El 10,LOCAL GOVT MECHANISM 422 <br /> 2.GUARANTEE ❑5.LETTER OF CREDIT ❑S.STATE FUND&CFO LETTER ❑99.OTHER: <br /> [13.INSURANCE [16.EXEMP770N ❑9.STATE FUND&CD <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one box to indicate which address should be used for legal nouftcazmns and mailing. <br /> Legal notifications end mailings will be sent to the tank owner unless box 1 or 2 is checked. ❑ 1.FACILITY k"2. PROPERTY OWNER 3.TANK OWNER 423, <br /> VII.APPLICANT SIGNATURE <br /> Certification: I certify that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNATURE OF <br /> DATE 424. PHONE 4u. <br /> -9-zb- 1.11416 e? <br /> NAME OF APP (print) ! 426. TITLE OF APPLICANT 4z7. <br /> STATE UST FACILITY NUMBER(Agency cam wly) 428. 1998 UPGRADE CERTIFICATE NUMBER(Agency we mly) 429. <br /> (See Data Element 1,above. <br /> 59 <br />