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�n PROGRAM CONSOLTDATF.D FC TANKS UNDERGROUND STORAGE TANKS - FACILITY (one page per site) Page I of TYPE OF ACTION ❑ 1.NEW SITE PERMIT ❑3.RENEWAL PERMIT ❑5.CHANGE OF INFORMATION ❑ 7TERMANENTLY CLOSED SITE (Check one item only) [14.AMENDED PERMIT specify change local use only ❑ 8.TANK REMOVED ❑&TEMPORARY SITE CLOSURE 400 I. FACILITY/ SITE INFORMATION BUSINESS NAME(Same as FACILITY NAME or DBA-Do�inp Busineu A:) 3 FACILITY ID" RC O 3 5 1'6 , +�AMN(ftitO z NEAL{�I ST CROSS STREET 401 FACILITY OWNER TYPE 4.LOCAL GENCY/DISTRICTa L�O(il-�#J i2o, SroCK IO ❑ I.CORPORATION ❑5.COUNTY AGENCY• BUSINESS1.GAS STATION Lj 3.FARM C1 5. COMMERCIAL ❑ 2.INDIVIDUAL ❑6.STATE AGENCY* TYPE 2.DISTRIBUTOR ❑4.PROCESSOR[-16. OTHER 403 ❑ 3.PARTNERSHIP ❑7.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 REMAINING AT SITE [rustlands? operates the UST(This is the contact person for the tank records.) 404 ❑ Yes 4No 405 405 II. PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 007 PHONE 408 MAILING OR STREET ADDRESS ao9 351 4D,A WXC C--- CITY 610STATE 411 ZIP CODE 412 61W(I To 4a PROPERTY OWNER TYPE Lj 1.CORPORATION ❑2.INDIVIDUAL U 4.LOCAL AGENCY/DISTRICT C1 6.STATE AGENCY [13.PARTNERSHIP ❑5.COUNTY AGENCY [17.FEDERAL AGENCY 413 III. TANK OWNER INFORMATION TANK OWNER NAME 414 PHONE 415 50M� MAILING OR STREET ADDRESS 616 CITY 417 STATE 418 ZIP CODE 419 TANK OWNERTYPE U 1.CORPORATION Lj 2.INDIVIDUAL 4.LOCAL AGENCY/DISTRICT El 6.STATE AGENCY 420 3.PARTNERSHIP 5.COUNTY AGENCY ❑7.FEDERAL AGENCY IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY TK)HQ 44- 1 1 1 1 1 1 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 [110.LOCAL GOVT MECHANISM ❑2.GUARANTEE ❑5.LETTER OF CREDIT ❑S.STATE FUND&CFO LETTER ❑ 99.OTHER: ❑3.INSURANCE ❑6.EXEMPTION ❑9.STATE FUND&CD 422 VI. LEGAL NOTIFICATION AND MAILING ADDRESS Check one box m indicate which address should be used for legal notifications and mailing. j Legal notifications and mailings will be sent to the unk owner unless box 1 or 2 is checked. y(3 1.FACILITY ❑2. PROPERTY OWNER [13.TANK OWNER 411 VII. APPLICANT SIGNATURE ' Ica tlon-I certify that the information provided herein is tme and accurate m the best of my knowledge. S NATURE PPLICANT DATE 024 PHONE 425 0//7/---`)0 q14 870 - 9 3* AME OF XPPLICANT(pfint) 626 TITLE OF APPLICANT 427 /NI 611AIZ9 G AA CIM61F,s M39NF1476/L, STATE UST FACILITY NUMBER(For iocm,.r.omy) 42e 1998 UPGRADE CERTIFICATE NUMBER(Fm local are only) 429 UPCF(1/99 revised) 171 Formerly SWRCB Form A