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ti+1 rp _ 'IFIED PROGRAM CONSOLIDATED FORM (Q PR a: \ JIV 2 3\ FAC#: UNDERGROUND STORAGE TANKS -FAC LIQ t n I.�`'b��' (one page rate) TYPE OF ACTION ❑ I.NEW SITE PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ].PERMANENTLY CLOSED SITE (Check one item only) 4.AMENDED PERMIT 8.TANK REMOVED ❑6.TEMPORARY SITE CLOSURE 4a0 I.FACILITY/SITE INFORMATION t_ BUSINE NAME(Sae u FACILITY NAME a DBA-Doing Bmh,us As) 3 FACIlATY eS dz( N2 N0 (f NEAREST CROSS STREET aoI FACILITY OWNER TYPE El 4.LOCAL AGENCY/DISTRICT' ❑ 1.CORPORATION ❑ 5.COUNTY AGENCY" BUSINESS 1.GAS STATION ❑ 3.FARM ❑ 5.❑ COMMERCIAL 2.INDIVIDUAL ❑ b.STATE AGENCY" TYPE ❑2.DISTRIBUTOR E] 4.PROCESSOR r-16.OTHER 403 ❑ 3.PARTNERSHIP El ].FEDERAL AGENCY' 02 TOTAL NUMBER OF TANKS Is facility on Indian Reservation or 'Ifowner of UST is a public agency:name of supervisor ofdivision,section or office which operates REMAINING AT SITE trustlands? the UST(This is the contact person for the bnk records) 404 ❑ Yes ❑ No 405 as IL PROPERTY OWNER INFORMATION PROPERTY OWNER NAME ,,/ N D nQ� `/ �Q�i 40]I PHONE 4og MAILING OR STREET ADDRESS `S ` t T- 409 CITY410 STATE 4D ZIP CODE �., 412 LE C�3 l.t 3�:4 PROPERTY OWNER TYPE El 1.CORPORATION 2.INDIVIDUAL El4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY rl 3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑7.FEDERAL AGENCY 413 III.TANK OWNER INFORMATION TANK OWNER NAME I 414 PHONE 415 MAILING OR STREET ADDRESS 416 CITY 411 STATE 418 ZIPCODE 419 TANK OWNER TYPE EI 1.CORPORATION El 2.INDIVIDUAL 04.LOCAL AGENCY/DISTRICT El 6.STATE AGENCY 426 ❑ 3.PARTNERSHIP ❑ 5.COUNTY AGENCY 117.FEDERAL AGENCY IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY(TK)HQ 44- 1 Call(916)322-9669 if questions arise 421 V.PETROLEUM UST FINANCIAL RESPONSIBILITY INDICATE METHOD(s) ❑ I.SELF-INSURED ❑4.SURETY BOND ❑ 7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM 1:12.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 beused for legal notifications and mailing. ❑ 1.FACILITY ❑2.PROPERTY OWNER ❑3.TANK OWNER 423 Legal notifications and maifing wip be sent to the lank owner uokss box 1 or 2 is checked. VII.APPLICANT SIGNATURE Certification-I certify that the information provided herein is true and accurate to the best ofmy knowledge. SIGNATURE OF APPLICANT DATE 424 1 PHONE 425 NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 427 STATE UST FACILITY NUMBER(rg mI ne a,b) 429 1998 UPGRADE CERTIFICATE NUMBER(For IMI mconly) 429 Is 1998 Compliant? UPCF(1/99 revised)