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42 <br /> LVIRVIED PROGRAM CONSOLIDATED FO , . n <br /> 0 1� TANKS yL�O�I K✓ <br /> UNDERGROUND STORAGE TANKS - FACILITYK"'te <br /> �(n7�C <br /> ,fo (One paPage_of_ <br /> TYPE OF ACTION .NEW PERMIT ❑3.RENEWAL PERMIT ❑5.CHANGE OF INFORMA N 7.PERMANENTLY CLOS p�fiE 400. <br /> (Check arle itemonly) ❑4.AMENDED PERMIT (Specify change) 8.TANK REMOVED ,7(l 11(77 <br /> ❑6.TEMPORARY SITE CLOSURE <br /> Vcc W G ��] , I. FACILTfY/SITE INFORMATION oma( a q •1 <br /> BUSINESS NAMEis..FACILITYNAME or DBA-Doing Business As) 3, FACILITY <br /> PR <br /> 0"- <br /> NEAREST CRO SSTREET sot. FACILITY OWNER TYPE 4.LOCAL AGENCY/DISTRICT• 402 <br /> 0 0- ❑ 1.CORPORATION ❑5.COUNTY AGENCY- <br /> BUSINESS U I.GAS STATION .FARM C15.COMMERCIAL 402. <br /> TYPE ❑2.DISTRIBUTOR E-14.PROCESSOR 6.OTHER "� 'INDIVIDUAL ❑6.STATE AGENCY- <br /> ,C )� 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: name of supervisor of division,section or 406. <br /> REMAINING AT SITE or trustIan s? office which operates the UST. (This is the contact person for the rank records.) <br /> ❑Yes No rotlo /l <br /> IL PROPERTY OWNER?NFORMATION <br /> PROPERTY OWNE NAME 407. PHONE 408 <br /> L oZ® e s o <br /> MAILING OR STREET ADDRESS <br /> - � 409. <br /> CITY ,r / f10 STATE 4", <br /> �/--C•/r� ZIP CODE y 412 <br /> PROPERTY OWNER TYPE ULCOPPORATION 2.[ND[VIDUAL U 4.LOCAL AGENCY/DISTRICT U&STATEAGENCY <br /> a3. <br /> PARTNERSHIP [15.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 4[4. PHONE 113. <br /> MAILING OR STREET ADDRESS 416. <br /> CITY / 417. STAT 4[s. ZIPCODE ) 419. <br /> Z-6 d �' �7 <br /> TANKOWNERTYPE LJ I.CORPORATION 2 .INDIVIDUAL 4.LOCALAGENCY/DISTRICT U&STATEAGENCY 420. <br /> PARTNERSHIP ❑S.COUNTY AGENCY [17.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY TK HQ 44- 1 7 1 1 1 1 1 Call 916 322-9669 if questions arise 421. <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ❑L SELF-INSURED ❑4.SURETY BOND [17.STATE FUND ❑t0,LOCAL GOVTMECRALNISM 422 <br /> ❑2.GUARANTEE ❑S.LETTER OF CREDIT ❑8.STATE FUND As CFO LEITER ❑99.OTHER: <br /> INSURANCE ❑6.EXEMPTION ❑9.STATE FUND&CD <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one box b indicate which address should be rued for legal muricariom and marling. <br /> Legal notifications and mailings will be sent to the tank owner unless box I or is cbeekad. ❑ I.FACILITY k2. PROPERTY OWNER ❑3.TANK OWNER 423. <br /> VII.APPLICANT SIGNATURET� <br /> Certification: I certify[bat the information Provided herein is true and accurate b the best of my kmwledge. <br /> SIGN OF APPLICANT DAT 424. PHONE 425, <br /> -g-6 ! <br /> NAME OF APPLICANT I) 426. TITLE OF APPLICANT 427. <br /> STATE UST FACILITY NUMBER(Agency we only) 428• 1998 UPGRADE CERTIFICATE NUMBER(Agency use mry) 429. <br /> (See Data Element I,above. <br /> UPCF Hwfwre-a(1/99).112 http://wry .unidocs.org Rev.02/16/00 <br />