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MAY-11-2010 11 :21 AM P. 03 <br /> TINTFIRD PROGRAM CON9011DATRD FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (am page pm site) PAP-of- <br /> TYPE <br /> age_uf_TYPE OF ACTION 1.NEW SITE PERMIT 3.RENEWAL PERMIT 5.CHANOE OF INFORMAT70N 0 7.PERMANENTLY CLOSED SITE <br /> (Conk oa boon asps) ❑4.AMENDED PERMIT -pedy obmge lad nee ady..,_.-. ❑ S.TANK REMOVED <br /> ❑6.TEMIPORARY SITE CLOSURE a*° <br /> L FACILITY/SITE INFORMATION <br /> B SINESSN (Semen FAMITYNA%0o,DSA-Oi,sRWwee At 7 FACILITYIDN I <br /> 31 <br /> NEAREST CR09 STREET rot FtyA���,CILITY OWNER TYP <br /> JonE 4,LOCAL AGENCY/DISTRICT" <br /> �- '.CORPORATION ❑5,C07INTY AGENCY* <br /> BU9INE L OA3 STATION 3.FARM U 5. COMMERCIAL ❑ 2.INDIVIDUAL ❑6.STATE AGENCY* <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR❑6. OTHER am ❑ 1.PARTNERSHIP ❑7.FEDERAL AGENCY* 03 <br /> TOTAL NUMBER OF TANKS IIs facility on Indian Rexrvstlon a •Ifawam of UST ie•puhtia egeary:same afaupemem erdNhlaq**orlon a ofEee Whleh <br /> REMAININGATSrIF 2 nustlttnde7 opemtea No UST(Thi*IetMmmaetpffMfadutWe rceaM.) <br /> a as © Yes ONO ass a06 <br /> IT, PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME A4 ,v .&ft ,4-.IYw i✓H 467 1 PHONE 3 rj� y bs <br /> SA esu Zo - 3 S- T 7 <br /> MAILING OR STREET ADDRESS /f Jj 10° <br /> �� lYa •'o'. - <br /> L 410 STATE ail ZIPCO C �/ u3 <br /> C W adab&a G sc�! <br /> PROPERTY OWNER .CORPORATION 2.INDIVIDUAL 4.LOCAL AGENCY/D15TRICT Uo.5FAIbAUhNCY <br /> El 3.PARTNERSHIP Cl 5.COUNTY AGENCY ❑7.P13DERAL AGENCY 413 <br /> III.TANK.OWNER INFORMATION <br /> JANK OWNYR ai4 <br /> ns <br /> s& s s 1339 �RE0" <br /> 6 <br /> MAILING OR STREET AVVFq <br /> 1Pro(o )4. Cd raS@t <br /> �C���ff 41 STATE 4u ZIP CODE at9 <br /> TANK OWNER TYPE . ORPO 91-IG 2.INDIVIDUAL Ll 4.LOCAL AGENCY/DISTRICT 6.STATE AGENCY 4w <br /> 3.PARTNERSHIP ❑5.COUNTY AGENCY 7.FEDERAL AGENCY <br /> IV.HOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> T HQ 44- 1 CRIT 916 322-9669 if uwdons Sligo 421 <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(*) ❑1.SELFdN9URED ❑4.SURETY BOND [37 STATE FUND ❑Ia.LOCAL GOVT MECHANISM <br /> ❑2.GUARANTEE. ❑5.LETTER OF CREDIT f f STATE FUND d CFO LETTER ❑ 99.OTHER: <br /> ❑3.INSURANCE ❑6.EXEMPTION ❑9.STATE FUND&CID a00 <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Ckwk bmtm' ala Whkh ton mad Por Sad nedfianom mdmMlna. FACILITY ❑3. PROPERTYOWNPR ❑3.TANXOWNER aYs <br /> LsSd mdifiWkss,sad mkW ai "I he ,m to We tmk oast soles,boa I m2 is ahseksd <br /> VII,APPLICANT SIGNATURE <br /> C ROMtoo-I atdy OW the hdannolm pmvidsd hettst sae and*sonar*to Ws bet cfsy kesWledRe. <br /> I ATURE OP LC A�3T 3a PHONE a <br /> DATF�-, / C1 <br /> N F APPLICANT(print) a.. TITLE OF APPLICANT <br /> AM S --�[ (� DSA 4,•& <br /> 3 ATE USTFACMITY NUMBER(Fm sJ vW wlyl 429 1998[7PGRADE CERTIFICATE MIMBER(Fer tas i,a alyl 'D9 <br /> UPCF(1/99 revised) 8 Formerly SWRCB Form A <br />