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IIFIED PROGRAM CONSOLIDATED FORM PR N: FAC N: UNDERGROUND STORAGE TANKS - FACILITY (one page per site) TYPE OF ACTION ❑ 1.NEW SITE PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION 7.PERMANENTLY CLOSED SITE (Check one item only) ❑4.AMENDED PERMIT ❑ S.TANK REMOVED ❑ 6.'IFNIPORARN SIIECLOSURF 140 I.FACILITY/SITE INFORMATION B SR4ESS NNN(S..FFA IUW ry J y�-Dome gm�.As) 3 FAC= IDH PR IDN S eVl 9 1 NEAREST CROSS STREET FACB.RY OWNER TYPE El 4.LOCAL AGENCV/DISTRICT' A r^ El FACILITY CORPORATION 'T u ❑5.COUNTY AGENCY' BUSINESS E] 1 GAS STATION ANDIVIDUAL ❑ 3.FARM 5.COMMERCIAL 2 ❑ 6,STATE AGENCY' TYPE E]2 DISTRIBUTOR ❑ 4.PROCESSOR E] 6.OTHER 403 ❑ 3.PARTNERSHIP [:17.FEDERAL AGENCY' 402 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 operates REMAINING AT SITE "Hands? the UST(This is the contact person for the tank records.) 404 ❑ Yes XN. 405 906 II.PROPERTY OWNER INFORMATION PROPERTY OWNER NAME • t�f,�j tj I �T e gtPHO � - y.L409 O MAILING OR STREET ADDRa 41204LAJF40 CRY S O(' � _� 4I0 STATE Ca 411 ZIP CODE �S-00 7 412 PROPERTY OWNER TYPE ❑ I.CORPORATION ❑ 2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT [:16.STATE AGENCY ❑3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY 413 III.TANK OWNER INFORMATION TANK OWNER NAME T w 1 nr / �r � 414 PHOINU� ` �2 9, aIs MALING OR STREET ADDRESS^+) /_G/ 416 2 _ CITY c�+0 alt NI TE " ale ZIP CODE J 4I9 TANK OWNER TYPE v ❑ 1.CORPORATION ❑ 2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY 420 ❑ 3.PARTNERSHIP ❑ 5.COUNTY AGENCY 1:17.FEDERAL AGENCY IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY(TK)HQ 44- Call(916)322-9669 if questions arise 421 V.PETROLEUM UST FINANCIAL RESPONSIBILITY INDICATE METHOD(s) ❑ 1 SELF-INSURED ❑4.SURETY BOND ❑ 7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM ❑2.GUARANTEE ❑5.LETTER OF CREDIT ❑ 8.STATE FUND&CFO LETTER ❑99.OTHER ❑3.INSURANCE ❑6.EXEMPTION ❑ 9.STATE FUND&CD 422 VI.LEGAL NOTIFICATION AND MAILING ADDRESS Check one box to indicate which address should be used for legal notifications and mailing. ❑ 1.FACILITY ❑2.PROPERTY OWNER ❑3.TANK OWNER 423 Legal notifications and mailing will be sent to the milk owner unless box I or 2 is checked VII.APPLICANT SIGNATURE Certification-I certify that the information provided herein is true and accurate to the best of my knowledge. SIGNATURE OF APPLICANT DATE 421 PHONE 425 NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 427 STATE UST FACILITY NUMBER(For lw.l fieaan) 429 1998 UPGRADE CERTIFICATE NUMBER(F«heelusewly) 429 Is 1998 Compliant? UPCF(1/99 revised)