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IFIED PROGRAM CONSOLIDATED FORM PRA: Nll� FAC N: UNDERGROUND STORAGE TANKS - FACILITY (one page per site) TYPE OF ACTION ❑ 1NEW SITE PERMIT ❑ 3.RENEWAL PERMIT ❑ 5 (-u.AN(,[ OFINFORMATION ❑ 7.PERMANENTLY CLOSED SITE (Check one item only) ❑ 4.AMENDED PERMIT gkeuh cimec toed ets .: '- ❑ 8.TANK REMOVED ❑6 1 F%IPOR\R1 l[I L Cl DCI RI 400 I.FACILITY/SITE INFORMATION 4_ BUSINESS NAME(S.as FACILITY NAME or URA-Doing Business A.) g FACILITYIDN PR IDN I NEAREST CROSS STREET 401 El OWNER TYPE 04 LOCAL,AGENCY/DISTRICT' ❑ L CORPORATION ❑ 5.COUNTY AGENCY' BUSINESSEl2-INDIVIDUAL El I'GAS STATION ❑ 3.FARM ❑ 5.COMMERCIAL [:] 3 PARTNERSHIP El 6.STATE AGENCY' TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR ❑ 6.OTHER 403 ❑ 7.FEDERAL AGENCY' 402 TOTAL NUMBER OF TANKS Is facility on Indian Reservation or gfowner of UST is a public agency.name of supervisor ofdivisim section or office which operates REMAINING AT SITE trustlands? the UST(This is the contact person for the tank records.) 409 ❑ Yea ❑No 405 406 II.PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407 PHONE 409 MAILING OR STREET ADDRESS 409 CITY 410 STATE 411 ZIP CODE 412 PROPERTY OWNER TYPE ❑ L CORPORATION ❑ 2.INDIVIDUAL ❑ 4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY ❑3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY 413 III.TANK OWNER INFORMATION TANK OWNER NAME 414 PHONE 415 MAILING OR STREET ADDRESS 416 CITY 417 1 STATE 418 ZIP CODE 419 TANK OWNER TYPE ❑ 1.CORPORATION ❑ 2.INDIVIDUAL ❑ 4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY 420 ❑ 3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY W.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY(TK)HQ 44- 1 Call(916)322-9669 if questions arise 411 V.PETROLEUM UST FINANCIAL RESPONSIBILITY INDICATE METHOD(s) ❑ I SELF-INSURED ❑4.SURETY BOND ❑ 7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM ❑2.GUARANTEE ❑5.LETTER OF CREDIT ❑ 8.STATE FUND&CFO LETTER 1199.OTHER ❑3.INSURANCE 116.EXEMPTION ❑ 9.STATE FUND&CD ass 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 nomcauses and mailing will be sent to the tank owner unless box 1 m 2 is checked. VII.APPLICANT SIGNATURE Ceniftcanon-I certify that the information provided herein is true and accurate to the best of my knowledge. SIGNATURE OF APPLICANT DATE 424 1 PHONE 425 NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 427 STATE UST FACILITY NUMBER ffer larel--h) 428 1998 UPGRADE CERTIFICATE NUMBER Lew bW use cuh) 429 Is 1998 Compliant? UPCF(1/99 revised)