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FIEDPROGRAM CONSOLIDATED F /n �I75 O TANKS N UNDERGROUND STORAGE TANKS - FACILITY (One page per site) Page_of TYPE OF ACTION 1.NEW PERMIT [13.RENEWAL PERMIT S.CHANGE OF INFORMATION ❑7.PERMANENTLY CLOSED SITE 400. (Check one item only) ❑4.AMENDED PERMIT (Specify change) ❑8.TANK REMOVED ❑6.TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION BUSINESS NAME(Sadnc as FACILITY NAME or DBA-Doing Business As) 3 FACILITY WINE COoNT'Ky STAtTID" ID* Ll NEAREST CROSS STREET 401. FACILITY OWNER TYPE ❑4.LOCAL AGENCY/DISTRICT* 402. e • k E TTLr MAEN L A IIJ ®,I.CORPORATION ❑5.COUNTY AGENCY* BUSINESS 1.GAS STATION 3.FARM ❑5.COMMERCIAL 407 [12.INDIVIDUAL ❑6.STATE AGENCY* TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR [16.OTHER ❑3.PARTNERSHIP ❑7.FEDERAL AGENCY* 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 406, REMAINING AT SITE or trust lands? office which operates the UST. (This is the contact person for the tank records.) 3 ❑Yes W No II. PROPERTY OWNER INFORMATION PROPERTY pOWNER NAM E 407. PHONE 408. !Lt v fHo'tbA at llUVr?3TMEiY1?S , LLL W- 806 -1 1 tta MING OR STREET ADDRESS - 409. X?- V*SO" +- s�, CITY 1141 t.4e I Tiff 410, STA 4u. ZIPS/soODE 412. PROPERTY OWNER TYPE XLCORPORATION ❑2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ?� 6.STATE AGENCY 413. ❑3.PARTNERSHIP [15.COUNTY AGENCY ❑7.FEDERAL AGENCY III.TANK OWNER INFORMATION TANKOWNERNAME 414. PHONELACE 415 Afi . IL( #tom M Ajvpg c�1'3 L.LL ?o9 - 3,6c) - 3633 MAILING O STREET ADDRESS 416. VW �6 Z v qa�'� S CITY I L f/ / *V 4n. STATE CA 41s. ZIP�J 0�.I-DE 419. TANK OWNER TYPE PQ 1.CORPORATION 2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 420. ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY(TK)HQ 44- 0 1 L y Call(916) 322-9669 if questions arise 421 V.PETROLEUM UST FINANCIAL RESPONSIBILITY INDICATE METHOD(s) ❑ 1.SELFJNSURED [14.SURETY BOND ❑7.STATE FUND ❑ 10.LOCAL GOV'T MECHANISM 432 [12.GUARANTEE ❑5.LETTER OF CREDII ❑8.STATE FUND&CFO LETTER ❑99.0'1'HER: ❑3.INSURANCE ❑6.EXEMPTION ❑9.STATE FUND&CD VI.LEGAL NOTIFICATION AND MAILING ADDRESS Check one box to indicate wbich address should be used for legal notifications and nailing. Legal notifications and mailings will be sent to the tank owner unless box I or 2 is checked. ® I.FACILITY ❑2. PROPERTY OWNER ❑3.TANK OWNER 423. VII.APPLICANT SIGNATURE Certification: 1 certify that the info tion provided herein is true and accurate to the best of my knowledge. SIGNATUOF APQLICANT DATE 024 PHONE 425, D�-2H - 06 tief- BDG- 11NQ NAME OF APPLICANT(print) 426. TITLE OF APPLICANT 427. SRNDEeP VN44 &WA.len STATE UST FACILITY NUMBER(Agency use only) 428. 1998 UPGRADE CERTIFICATE NUMBER(Agency use only) 429• (See Data Element 1,above. UPCF Hwfwre-a(1/99)-1/2 http://www.unidoes.org Re,.02/16/00