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DNTFIF.D PROGRAM CONSOLIDAI ED FORM W12111102- <br /> 2 I7 OL TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page per site) Page_L of� <br /> TYPE OF ACTION ❑ 1.NEW SITE PERMIT ❑3.RENEWAL PERMIT ❑5.CHANGE OF INFORMATION ❑ 7.PERMANENTLY CLOSED SITE <br /> (Check one item only) ❑4.AMENDED PERMIT specify change local use only. ❑ S.TANK REMOVED <br /> P,6.TEMPORARY SITE CLOSURE 400 <br /> I. FACILITY/SITE INFORMATION <br /> BUSINESS <br /> NAME(Saxe as FACILITY NAME.,DBA-Doing Business As) 3 1 FACILITY ID# 1 <br /> NEAREST CROSS STREET aol FACILITY OWNER TYPE LLj 4.LOCAL AGENCY/DISTRICT• <br /> e ry1�� 1 1 D J( 1.CORPORATION ❑5.COUNTY AGENCY* <br /> BUSINESS 1.GAS STATION ARM Lj p5�. COMMERCIAL ❑ 2.INDIVIDUAL ❑6.STATE AGENCY* <br /> TYPE ❑2.DISTRIBUTOR [14.PROCESSOR fesL OTHER 403 ❑ 3.PARTNERSHIP ❑7.FEDERAL AGENCY' 402 <br /> TOTAL NUMBER OF TANKS [s facility on Indian Reservation or *If owner of UST is a public agency:name of supervisor of division,section or office which <br /> REMAINING AT SITE trustlands? operates the UST(This is the contact person for the tank records.) <br /> 404 ❑ Yes 9No 405 406 <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408 <br /> QZ$ qC)l qql) <br /> 409 <br /> MAILING OR STREET ADDRESS <br /> CITY 50A 010 STATE 411 ZIP CODE 4¢ <br /> � C,a- get-683 <br /> PROPERTY OWNER TYPE .CORPORATION 2.INDIVIDUAL Lj 4.LOCAL AGENCY/DISTRICT LJ6.STATEAGENCY <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY 413 <br /> III.TANK OWNER INFORMATION <br /> TAN IWNERNAME 414 PHONE 415 <br /> Y 42sgo17qD) <br /> PeA416 <br /> MAILING OR STREET ADDRESS <br /> D S' gin SjoaV <br /> 417 1 STATE ala Z[�P7 CODE e 419 <br /> nn tn�,� <br /> TANK OWNER TYPE CORPORATION Lj 2.INDIVIDUAL Lj 4.LOCAL AGENCY/DISTRICT LJ6.61AIhAULNCY 420 <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY TK HO 44- 1 D Call 916 322-9669 if questions arise 421 <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) 5M.SELF-INSURED ❑4.SURETY BOND ❑7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM <br /> ❑2.GUARANTEE ❑5.LETTER OF CREDIT ❑8.STATE FUND&CFO LETTER ❑ 99.OTHER: <br /> ❑3.INSURANCE ❑6.EXEMPTION ❑9.STATE FUND&CD 422 <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one box to indicate which address should be used for legal notifications and mailing. 423 <br /> Legal notifications and mailings will be sent to the tank owner unless box I or 2 is checked. ❑ 1.FACILITY PROPERTY OWNER [13.TANK OWNER <br /> VII.APPLICANT SIGNATURE <br /> Certification-I certify that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNyI{1REO APPLICANTS <br /> DATE azo PHONE 425 <br /> (AK/fav l/JIP)� I � 1 -26-02 �f2528�&� 21�3 <br /> NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 427 <br /> o 6 Pz A6WT-Fba-9W_I�I[ Q4;Ll <br /> STATE UST FACILITY NUMBER(For local use only) 428 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 <br /> UPCF(1/99 revised) 8 Formerly SWRCB Form A <br />