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TTNIFTrrN PROGRAM CONSOT.TDATF,D FORM I <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACMfl Y <br /> (one page per situ) pap of-- <br /> TYPE <br /> f_TYPE OF ACTION 1.NEW SITE PERMIT ❑3.RENEWAL PERMIT ❑S.CNANGE OF INFORMATION ❑ 7PERMAHENTLY CLmEDSITE <br /> (UxJ[one iron only []4.AMENDED PERMIT .pacifych=p locelmwawy ❑ S.TANK REMOVED <br /> 0 4TEMPORARY STIE CLOSURE 4m <br /> L FACILITY J SITE INFORMATION <br /> BU NAME fs.er FACf12TY`UMEorDBA-Doke w.I s FACILITY rap <br /> C 6MEER, <br /> NEAREST CROSS An FACT ITY OWNER TYPE 4,LOCAL AGENCY/DISTRICI` <br /> ❑ 1.CORPORATION D 5.COUNTY AGENCY" . <br /> BUSINESS - 1.GAS STATION U 3.FARM 05 COO.¢RCIAL :❑ 2-norvmUAL j]6.STATE AGENCY- <br /> TYPE 02-twr IBUTOR 04.PROCFSSO . OTHER AD ❑ 3.PARTNERSHIP - ❑7.FEDERAL AGENCY- <br /> TOTAL NUMBER OF TANKS Is facility on Indian Resonation of •If w of UST u a public agmcy:u of of diviaim aerJim w o8xc vrhirh - <br /> RFMAWAIGATSR'E / trustlands? opv theUSrrfboutheoom pc forthesmkumrdc) <br /> // 4a ❑ Yesewo <br /> xf.`udtl { IL PROPERTY OWNER INFORMATION C <br /> F PROPERTY WNEFL NAME .5•� r r c ,.iou h� �+ <br /> PHONE <br /> �✓ <br /> crn .Ip sraTEC� .kk ZIP CODE <br /> F <br /> 7 PROPERTY OWNER TYPE .CORPORATION E12.1NDIVIDUAL jJ4.LOCAL AGENCY/DISTRICT U6.STATEAGENCY <br /> a- ❑3.7ARTNERSHIF ❑5.COUNTY AGENCY ❑7.FIDIItAL AGENCY 40 <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME T 414 PHONE .0 <br /> i <br /> MAII.BJG OR STREET ADD 4165 _ / <br /> -CITY - d(/ .n STA // us .ZIP CODE y� .w <br /> XANK OWNER TYPE .CORPORATION 2.INDIVIDUAL U4.LOCAL AGENCY/DISTRICT Lj 6.STATE AGENCY 7Z <br /> i 3.PARTNERSHIP - 5.COUNTY AGENCY 0 7.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY HQ 44- 1 Call 916 322-9669 if questions arise 4=I <br /> V-PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> - DOICATE METHOD(s) ❑1.SELF-INSURED ❑4.SURETY BOND D 7.STATE FUND 01 O.LOCAL GOVT MECHANISM <br /> D 2.GUARANTEE 0 5.LETTER OF CREDIT C)8.STATE I=&CFO LETTER 0 99.OT'FMR: <br /> --E54-INSURANCE 06.EXEMPTION D9.STATEFUND&CD <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Cbmk as bo.mmim,which a ,.houkd be u.d for kpl nodfieatims audsa.imr& <br /> rapt noufamionr and mailings will be sentbmetaak owner..I.boa 1.2a checked. 101.FAa ITY 02- PROPERTY OWNER 133.TANK OWNER 4D <br /> VII.APPLICANT SIGNATURE <br /> Cndfiotim-I ratify the the information provided herein is uue and amuse m the ben of my knowledge. <br /> SIGNAT,19EE OF APPLICANT DATE e PHQI 3 � 4u <br /> f&-P ��©© <br /> QF'APPLICANT(pnot) 426 TITLE OF APPLICANT <br /> ``TI 4� 1998 UPGRADE CERTIFICATE NUMBER fFe.mismrl 'tT <br /> STA UST FACILITY U ivv:k.si rar p <br /> c <br /> UPCF(1199 revised) 8 Formerly SWRCB Form A <br />