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IiNIF '7 PROGRAM CONSOLMATRD FORM <br /> +' ... TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page per Site) Page_of <br /> TYPE OF ACTION 1.NEW SITE PERMIT Q 3.RENEWAL PERMIT Q 5ZHANGE OF INFORMATION Q 7PERMANENTLY CLOSED SITE <br /> (Chat ora Nem eery Q 4.AMENDED PERMIT ryaify hutge 10021-001Y ❑ 8.TANK REMOVED <br /> ❑6.TEMPORARY SITE CLOSURES 4m <br /> s e L FA 1 EMRMATION <br /> 17 <br /> BU NAME(s .FACILT(YNAr4E.DBA-Duey w) FAC <br /> C G 'S oC G a <br /> NEAREST CROSS /' ,(J r BB(7. _ 4m FACILITY OWNER TYPE 4.LOCAL AGENCY/DISIRICT" <br /> ❑ 1.CORPORATION []5.COUNTY AGENCI^ <br /> BUSINESS Lj 1.GAS STATION Lj 3.FARM 5 COMMERCIAL 0 2.INDIVIDUAL ❑6,STATE AGENCY- <br /> TYPE r32-DISTRIBUTOR ❑4.PROCESSObill OT'IIER 4m ❑ 3.PARTNERSHIP - ❑7.FEDERAL AGENCY- <br /> TOTAL NUMBER OF TANKSIs facility on Indiraeyery Rnon or 'I o of UST u a pubic ageory:orme of Zu __ for of Lcmt✓4 a m oH.eheh <br /> REMAI I NG ATSITE / trusdands? opram the UST M"u the oamact petsoo fm the Mk muds) <br /> as ❑ Ya o <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 4m PHONE - <br /> �' <br /> MAILING R ADDRESS <br /> CITY 410 STATE ^ 411 ZIP CODE 4D <br /> - PROPERTY OWNER TYPE .CORPORATION jJ2.INDIVIDUAL Lj 4.LOCAL AGENCY/DISTRICT U 6.STATE AGENCY <br /> P: ❑3.PARTNERSHIP 0 5.COUNTY AGENCY ❑7.FEDERAL AGENCY 40 <br /> 1 <br /> III.TANK OWNER INFORMATION <br /> f 7:MAU7_1NG <br /> WNER NAME T i 4M PHONE 40 i <br /> i ! G Lff C o2 D <br /> ( OR STREM ADD SS 416 <br /> _ CITY 417 STA ata ZIP CODE as <br /> TANK 0WNEkTYPE .CORPORATION LJ2.INDIVIDUAL Lj A.LOCAL AGENCY/DISTRICT Lj 6.STATE AGENCY 4m <br /> ❑3.PARTNERSHIP 0 5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> W.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY HQ 44 1 1 1 1 1 Call 916 322-9669 if questions arise <br /> V_PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> NDICATE METHOD(s) ❑ 1.SELF-INSURED ❑4.SURETY BOND ❑7.STATE FUND Z1 10.LOCAL GOVT MECHANISM <br /> ❑2.GUARANTEE ❑5.LEITER OF CREDIT [J S.STATE FUND CFO LETTER D 99.OTHEi <br /> �!�INSURANCE ❑6.EXEMPTION 0 9.STATE FUND&CD 4a <br /> V1.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> - Ort ora b0xmiodi02e r6irb addrta,IwWa be usd for kplvotirrmmsaoomeilmg <br /> le¢I amfiemoos sod®ftgp will be Gent m tnc tank ora uu1 a box 1w2 o ceA Q L.FACDSTY ❑2 PROPERTY OWNER ❑3.TANK OWNER 402 <br /> VII.APPLICANT SIGNATURE <br /> Catiftmion-1 catlfytha the udcr=tion provided herein u true and amtrate m the best of knowledge. <br /> SIGNA OF APPLICANT ri4DATE .� PHQtyf23 8--3r <br /> 1-1 <br /> N VE APPLICANT(print) 4>6 TITLE OF APPLICANT <br /> - <br /> STA UST FACILITY NU .F«mia.� ty� 4D 1998 UPGRADE CERTIFICATE NUMBER(6r <br /> mm:m>�� 4t0 <br /> C. <br /> UPCF(1199 raised) 8 Formerly SWRCB Form A <br />