Laserfiche WebLink
y <br /> UNIFIED PROGRAM CONSOLIDATED FORM O :7172/ <br /> 7 V <br /> TANKS � �/� <br /> UNDERGROUND STORAGE TANKS - FAC 3)-X1197 K-e <br /> (One page per site) Pegg-Of- <br /> TYPE OF ACTION ❑ 1.NEW PERMIT 0 3.RENEWAL PERMIT P4.CHANGE OF INFORMATION ❑7.PERMANENTLY CLOSED SITE 400 <br /> (ClrOk ON hero only) ❑4.AMENDED PERMIT (Specify change) ❑8.TANK REMOVED <br /> ❑6.TEMPORARY SITE CLOSURE <br /> ;1I1d$ 1PE,1R1F1A1jNF <br /> BUSINESS NAME(sar,m.FACILITY NAME.DBA-Doing Bueklf,Aa •- <br /> ,t ) 5. FACILITY <br /> NEAREST CROSS STREET eo1. A%ITY OWNER TYPE U 4,LOCAL AGENCY/DISTRICT' ba <br /> A \ S 1.CORPORATION El 5,COUNTY AGENCY* <br /> BUSINESS ,GAS STATION 113.FARM S.COMMERCIAL 403. ❑2.INDIVIDUAL ❑6.STATE AGENCY* <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR ❑6.OTHER [13.PARTNERSHIP ❑7.FEDERAL AGENCY* <br /> TOTAL NUMBER OF TANKS 404 1 Is facility on Indian Reservation 405. 0 I owner of UST is a public agency:name of supervisor of division,moon or 406. <br /> REMAINING AT SITE or oust lends? office whioh operates the UST- (This is the wntact person Por the tank records.) <br /> 3 ❑Yea ANO <br /> ._...,. <br /> PROPERTY ER NAM -T-� em, PHONE <br /> (VPcSq Do L14 <br /> MAILING OR TREET ADDRESS CA <br /> f e L( LAJ0e1d6' �fS� S� e09 <br /> CITY 410. STATE 411, 1 ZIP CODE at <br /> i,,.)c 0d(3s-le CA <br /> PROPERTY OWNER TYPE OA1.CORPORATION U2.1NDIVIDUAL, Lj 4.LOCAL AGENCY/DISTRICT 06.STATE AGENCY <br /> ❑3.PARTNERSHIP [15.COUNTY AGENCY ❑7,FEDERAL AGENCY <br /> TANK OWNERNAM 414. HONE <br /> PS AP <br /> nl,��Sv1 6u vd� 3+3�' ;1; <br /> MAIL D 1>„STREE;ADDRE3C. J U416 <br /> 9d t�J iJ ed ' C�.. • �'.Sr�''SCl• � <br /> C 417. STATE 41a, ZIPCOD 419, <br /> �Ln G4 <br /> TANKOWNERTYPE 1.CORPORATION 2.INDIVIDUAL 4.LOCAL AGENCY/DISTRICT 6.STATE AGENCY 420. <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> TY K Hq 44- yyd.ssrs�r y CRIT 916 322-9669 i uestions arise 421. <br /> Ai-•aTnef4 'e <br /> INDICATE METHOD(s) C31 SELF-INSURED F ❑A SURETY BOND ❑7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM 422. <br /> ❑2.OUARANTEE ❑$ LETTER OF CREDIT Z:S.STATE FUND&CFO LETTER n ❑99.OTHER. <br /> EI 3.INSURANCE ❑5.EXEMPTION ❑9.STATE FUND&CD <br /> Jfr _ r 'C�LV'FiIE 1'I 'A1ikahI1'V('�la+,�RsiVu ' c1 -p`.. _ w <br /> a ; <br /> Check om box to Indicate which address should be used tar legal notifications and mailing. <br /> LgN tan&atlona and maillngf will be sent to the tank owner unless box l or 2 Is checked. W `.FACILITY ❑2. PROPERTY OWNER �❑3.TANK OWNER 42). <br /> lisp: 1 Ca1Nfy <br /> flat the Infortmtion provided herein is nue and accurate to the beat of my kmwledge. <br /> NATURE OF AP LICA DATE424. PHONE `� y425. <br /> - <br /> OF APPLICANT(print) 426. TTTLE OF APPLICANT 427. <br /> STATE UST FACILITY NUMBER(Agency w.,ry) 421. 1998 UPGRADE CERTIF'^s TE NUMBER(Agency urs an),) <br /> (See Data Elerrrent I,above. <br />