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I Yl1 al <br /> L. _ IED PROGRAM CONSOLIDATED FOR <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (One page per site) Page_of <br /> TYPE OF ACTION 94tNEW PERMIT ❑3.RENEWAL PERMIT 5.CHANGE OF INFORMATION ❑7.PERMANENTLY CLOSED SITE °00. <br /> (Check one item only) [14.AMENDED PERMIT (Specify change) ❑B.TANK REMOVED <br /> ❑6.TEMPORARY SITE CLOSURE <br /> I. FACIIdTY/SITE INFORMATION <br /> BUSINESS NAMES.as FACILITY NAME or DI 1 1: nlif As) 3. FACILITY � <br /> r C©c� Sa �GN t �59 <br /> NEAREST CROSS STRE T dol. FACILITY OWNER TYPE 4.LOCAL AGENCY/DISTRICT• 002 <br /> 1 1 E]1.CORPORATION ❑5.COUNTY AGENCY' <br /> BUSINESS1.GAS STATION 3.FARM 5.COMMERCIAL 493. CG 2.INDIVIDUAL ❑6.STATE AGENCY' <br /> TYPE ❑2.DISTRIBUTOR [14.PROCESSOR ❑6.OTHER ❑3.PARTNERSHIP ❑7.FEDERAL AGENCY" <br /> TOTAL NUMBER OF TANKS 404 Is facility on Indian Reservation 405. •If owner of UST is a public agency:Dame of supenisbr of division,section or 405. <br /> REMAINING AT SITE or trust lands? office which operates the UST. (This is the contact persc%for the tank records.) <br /> []Yes ❑No <br /> IL PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME R y <br /> rt•1 f 'n -S r y 007 PHONE 408. <br /> VY/h 2,>V 3 6y3 <br /> MAILING OR STREET ADDRESS 409. <br /> ' f I ro, / 4u. ZIP�C�fODE j s 412. <br /> d10. STAT�' 1 •'f •' <br /> CITY �� � / _ D <br /> PROPERTY OWNER TYPE LILCORPORATION EKINDIVIDUAL LJ4.LOCALAGENCYIDISIKIUI 6.STATE AGENCY a12. <br /> ❑3.PARTNERSHIP [15.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> M.TANK OWNER INFORMATION <br /> TANKOWNERNAME t? ,,Lctrl G; 1-J 414. 1 PHONE 415. <br /> MAILING OR STR'E,EJJT ADDRESS aaLC `/ 41s. <br /> P11 11 R <br /> CITY 4n. STATE as. ZIP CODE dig. <br /> f L�1 <br /> TANK OWNER TYPE 11I.CORPORATION 2.INDIVIDUAL 4.LOCAL AGENCY/DISTRICT 6.STATE AGENCY 420. <br /> • <br /> [13.PARTNERSHIP [15.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY TK HO 44- Call 916 322-9669 if questions arise 421. <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) .SELF-INSURED ❑4.SURETY BOND ❑7.STATE FUND [110.LOCAL GOVT MECHANISM 422 <br /> .GUARANTEE ❑5.LETTER OF CREDIT ❑B.STATE FUND&CFO LETTER 1199.OTHER: <br /> V.INSURANCE ❑6.EXEMPTION ❑9.STATE FUND&CD <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one boa to indicate which address should be used for legal notifications and mailing. J <br /> Legal notifications and mailings will be sent to the tank owner unless box 1 or 2 is checked. ❑ 1.FACILITY 22. PROPERTY OWNER ❑3.TANK OWNER 423 <br /> VII.APPLICANT SIGNATURE <br /> Certification: 1 certify dtat the information provided herein is true an curate to the best of my knowledge. <br /> / d24. O '-��j� 425. <br /> SIGNATURE OF APPLICANT �J` DATE' a(y� OC PHONE Y � <br /> NAME OF APPLICANT(print) lJ` 426. TITLE OF APPLICANT °27. <br /> ��_ srXl�� Dia <br /> STATEUST FACILITY NUMBER(Agmry use Daly) 428 1 1998 UPGRADE CERTIFICATE NUMBER(Agmcy ureonly) 429. <br /> (See Data Element 1,above. <br /> UPCF Hwfwre-a(1/99)-1/2 http://www.unidocs.org Rev.02/16/00 <br />