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ITNIFIF,D PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGF, TANKS - FAir = TANKS <br /> ' T (one page per Sim) page_of_ <br /> TYPE OF ACTION 1.NEW SITE PERMIT ❑3.RENEWAL.PERMIT LJ 5-CHANGE OF INFORMATION ❑ 7.PERMANENTLY CyOSEDSDE <br /> (mak one roan adY D 4.AMENDED PERMIT rymvfy ub-F'mal-only ❑ S.TANK REMOVED <br /> ❑6.TEh1PORARY SITE CLOSURE <br /> L FACn TTYI SITE INFORMATION <br /> BUS S NATvSE(aas.FAC62TV w.ME�BA-!>aa� An FACILITY M / lip <br /> / <br /> C G (! o(0) <br /> NEAREST CROSS - 40l FACTLIT'Y OWNER TYPE 4.LOCAL AGENCY/DISTRICT, <br /> /T / ❑ 1.CORPORATION n 5.COUNTY AGENM- I^� <br /> BUSINESS - 1.GAS STATION 3.FARM <br /> L MERCIAL n 2.INDIVIDUAL ❑6.STATE AGENCY- I/ <br /> TYPE OZDISTRIBUTOR n4.PROCFSSO�, ER An � 3.PARTNERSHI 07.FEDERAL AGENCY- 4m to <br /> TOTAL NUMBER OF TANKS Is facility on Indiantion cr •B owtrs of UST i a public agmry:name of wpaviwr of diyidnq Saxon or off"which <br /> REMAINING ATSCIE MLSdands? "enao,the LIST MAA u she menet peSoo fmthe omt aemrdc) <br /> +� ❑ Ya o Oro -© a <br /> �p/yL IL PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME $b tr c 4m PHONE <br /> eC .� ®,�s GAO ?' wa1{;ry �lab ell <br /> .� <br /> MAILING 9RSTREEI AmvRSSz <br /> ®✓, GOO <br /> CITY O � Ito STATEIII ZIP COD �O 4u <br /> PROPERTY OWNER TYPE .CORPORATION 2.INDIVIDUAL 4.LOCAL AGENCY/DISTRICT6.STATEAGENCY <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY 40 <br /> j <br /> IID TANK OWNER INFORMATION <br /> IANK OWNER NAME 4u PHONE p' 45 <br /> MAII.ING OR STREET ADD SS _ / 416 <br /> 4n 1 STA(T AuZfP CODE AN _ <br /> TANK O -TYPE .CORPORATION 2.IN'DIVIDUA1 4.LOCAL AGENCY/DLSTRTCI 6.STATE AGENCY am <br /> ❑3.PARTNERSHIP 5.COUNTY AGENCY 7.FEDERAL AGENCY <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY H 44 Call 916 322-9669 if questions arise al <br /> V_PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE MMOD(s) ❑1.SELF-INSURED n 4.SURETY BOND 07.STATE FUND D 10.LOCAL GOVT MECHANISM <br /> r-)2. ❑5.LE=OFCREDIT nS.STATE FUND&CFO LETTER n 99.OTH <br /> �S�TNSUILANCE n6.EXEMPTION 09.STATEFUND&CD - 4a <br /> VI.LEGAL NOTIFICATION AND MAILWG ADDRESS <br /> mak aae hnibiodieue whleh addtrs shonld be uaedfor legal nodfwtionr aodmailmg. _ <br /> I4N noditatimsaM maiWp«ill he sem m meant owns urdm box l m2 h nhdxd n I.FACNTY ❑2 PROPERTY OtNNp( CT 3.TANK OWNER aD <br /> VII.APPLICANT SIGNATURE <br /> Ceti6tnim-1 cadfythe me infomotion mvided herein is me and amore w the hes of my knowledge. <br /> SIGNA OF APPLICANT DATE PH au <br /> Q�APPLICANT(print) 4� TITLE OF APPLICANT <br /> STA`A UST FACILITY NUM isa f,ml,,.< p 'v 1998 UPGRADE CERTIFICATE NUMBER for rap ^p <br /> UPCF(1/99 raised) 8 Formerly SWRCB Form A <br />