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ED PROGRAM CONSOLIDATED FOWW Id2 51 ( MP <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILIGTYge per site) Page_of_ <br /> TYPE OF ACTION ❑1.NEW PERMIT ❑3.RENEWAL PERMIT ❑5.CHANGE OF INFORMATION [17.PERMANENTLY CLOSED SITE 400. <br /> (Check one item only) <br /> ❑4.AMENDED PERMIT (Specify change) ❑8.TANK REMOVED <br /> ❑6.TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION <br /> BUSINESS Nh�E(S FACILITY NAME or BA-Doing Business As) 3. ID#�1p FACILITY 1. <br /> ` � r0 OSS SIRE T 401. FACILITY OWNER TYPE ❑4.LOCAL AGENCY/DiSTRICT* aoz. <br /> NEAREST CR <br /> E] 1.CORPORATION ❑5.COUNTY AGENCY* <br /> BUSINESS 1.GAS STATION ❑3.FARM E]5.COMMERCIAL 403. q2.INDIVIDUAL ❑6.STATE AGENCY* <br /> 3.PARTNERSHIP ❑7.FEDERAL AGENCY* <br /> TYPE F12.DISTRIBUTOR F14.PROCESSOR [:]6.OTHER El 3. <br /> aob. <br /> TOTAL NUMBER OF TANKS 404. Is facility on Indian Reservation 405 *If owner of UST is a public agency: name of supervisor of division,section or <br /> REMAINING AT SITE <br /> or trust lands? office which operates the UST. (This is the contact person for the tank records.) <br /> ❑Yes 9No <br /> 11. PROPERTY OWNER INFORMATION <br /> 407. PHONE q <br /> PROPERTY OWNE ME /�UL MAILING OR SJRf ET A SS <br /> 66 E 411 ZIP CODE CITY 14 qs QPROPERTY OWNER TYPE ❑ I.CORPORATION 2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENC <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> III.TANK OWNER INFORMATION <br /> ala. PH E at5 <br /> L C-7 <br /> TANK OWNER NAME ` D sq L � _C <br /> � ale. <br /> MAILING OR STREET ADDRESS 11r,61/ 14 <br /> CITY <br /> 417 ST E CA 41 . ZIP CODE „ _ 419 <br /> S7-v Soy <br /> TANK OWNER TYPE ❑ 1.CORPORATION 2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY azo. <br /> 3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ <br /> Call 916 322-9669 if questions arise 421. <br /> I( V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) 1.SELF-INSURED ❑4.SURETY BOND ❑7.STATE FUND ❑10.LOCAL GO`'I MECHANISM a2z <br /> ❑2.GUARANTEE <br /> ❑5.LETTER <br /> EEXEMPTIOF CREDIT ❑❑9.STATE FUND&CD 8.STATE FUND&CFO LETTER ❑99.OTHER: <br /> INSUR <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one box to indicate which address should be used for legal notifications and mailing. 423. <br /> Legal notifications and mailings will be sent to the tank owner unless box I or 2 is checked. ❑ 1.FACILITY [:12. PROPERTY OWNER q3.TANK OWNER <br /> VII.APPLICANT SIGNATURE '1 <br /> PSTATE <br /> certify t t the info tion provided herein is true and accurate to the best of my knowledge. 425 <br /> DATE f 424. PHONE <br /> OF LIC <br /> 426 TITLE OF APPLICANT 427 <br /> APPLICA T( �n <br /> 1"3,4 /l/C a29 <br /> T FACILITY NUMBER(Agency use only) 4ze. 1998 UPGRADE CERTIFICATE NUMBER(Agency ase only) <br /> lement 1,above. <br /> UPCF Hwfwrc-a(1/99)-1/2 <br /> http://www.unidocs.org Rev.02/16/00 <br />