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� vIFIED PROGRAM CONSOLIDATED FOR �so 'Z(`j 103 FAC M: <br /> UNDERGROUND STORAGE TANKS -FACILITY (�P pl jg03 <br /> (one page per site) <br /> TYPEOFACTION ❑ I.NEW SITE PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ,�, SITE <br /> (Check one item only) ❑ 4.AMENDED PERMIT L✓J'STANK <br /> TANK REMOVED <br /> ❑6.TEMPORARY SITE CLOSURE 400 <br /> I.FACILITY/SITE INFORMATION <br /> BUS SS NAM(Sx7 u FACRITY NAME m DBA-Doing Bad.,As) 3 FACILITY IDM PR IDM <br /> $y� osz X860 1 <br /> NEAREST CROSS STREET j <br /> _zegs 141) N FACILITY OWNER TYPE <br /> r / 4oI ❑ 4.COUNTY <br /> 2G�'/ ,❑�/L CORPORATION ❑ 5.COUNTY AGENCY" <br /> BUSINESS ❑ 1,GAS STATION ❑ 3.FARM ❑ 5.COMMERCIAL L� 2'INDIVIDUAL <br /> TYPE ❑ ❑ 3.PARTNERSHIP ❑ 6.STATEAGENCY• 402 <br /> 2.DISTRIBUTOR E]4.PROCESSOR OTHER am ❑ 7.FEDERAL AGENCY* <br /> TOTAL NUMBER OF TANKS Is facility on Indian Reservation or *fawner ofUST is a public agency:name ofsupervisor ofdivision,section or office which operates <br /> REMAININGg T SITE trusdands? the UST(This is the contact person for the tank records.) <br /> 11ed <br /> 404 1-1 Yes E�No 4W5 as <br /> II.PROPERTY OWNER INFORMATION <br /> i r l.Wr.6r4er <br /> PROPERTY OWNER NAME rr ao? PHONE nog <br /> �ir /1h <br /> MAI,INGOR STREET ADDRESS <br /> E419 <br /> CITY oto STATE_ I 411 2SP CODE^ 412 <br /> C/A c-/S <br /> PROPERTY OWNER TYPE ❑ 1.CORPORATION [r2.INDIVIDUAL ❑ 4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY <br /> ❑3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY 413 <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> aS ctr�T9e <br /> MAILING OR STREET ADDRESS <br /> 416 <br /> CITY 417 STATE 418 ZIP CODE 419 <br /> TANK OWNER TYPE ❑ I.CORPORATION ❑ 2.INDIVIDUAL ❑ 4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY 420 <br /> 1:13.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- Call(916)322-9669 if questions arise 421 <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ❑ I,SELF-INSURED ❑4.SURETY BOND ❑ 7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM <br /> ❑2.GUARANTEE 1:15.LETTER OF CREDIT ❑ 8.STATE FUND&.CFO LETTER ®'�9.OTHER (010 4e) <br /> ❑3.INSURANCE ❑ 6.EXEMPTION ❑ 9.STATE FUND&CD an <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one box to indicate which address should be used for legal notifications and mailing. ❑ 1.FACILITY L3 2.PROPERTY OWNER ❑3.TANK OWNER 423 <br /> Legal notifications and mailing will be sent to the lank owner unless box 1 or 2 is checked. <br /> VII.APPLICANT SIGNATURE <br /> Certification-1 certify that the information provided herein is true and accurate to the best army knowledge. <br /> SIGNATURE OF APPLICANT DATE 424 PHONE 425 <br /> NAME OF APPLICANT(print) a 426 TITLE OF APPLICANT 427 <br /> STATE UST FACILITY NUMBER(For loml ue only) 429 1998 UPGRADE CERTIFICATE NUMBER(Farkmlmconly) 429 <br /> Is 1998 Compliant? <br /> UPCF(1/99 revised) � - <br />