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u2 z <br /> VIED PROGRAM CONSOLIDATED FO <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (One page per site) Page_of_ <br /> TYPE OF ACTION L NEW PERMIT <br /> (Check one item only) ❑3•RENEWAL PERMIT ❑5.CHANGE OF INFORMATION <br /> ❑7.PERMANENTLY CLOSED SITE 400. <br /> ❑4.AMENDED PERMIT (Specify change) ❑8.TANK REMOVED <br /> ❑6.TEMPORARY SITE CLOSURE <br /> 7S�ESq�A1"' teI. FACILITY/SITE INFORMATIONe as FACILITY NAME or DBA-Doing Bussinesss A1s 3. FACILITY <br /> ,�11/1 I i 1. <br /> NEA{tEIST�CROSS SD71 <br /> TET /xa 1/ ao ILIT ❑Y OWNER TYPE 4.LOCAL AGENCY/DISTRICT* 402. <br /> OCA FAC❑ <br /> I.CORPORATION ❑5.COUNTY AGENCY* <br /> BUSINESS hd 1.GAS STATION ❑3.FARM M 5.COMMERCIAL 403. ❑ .INDIVIDUAL El 6.STATE AGENCY* <br /> TYPE ❑2.DISTRIBUTOR El 4.PROCESSOR ❑6.OTHER 3.PARTNERSHIP <br /> ❑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 trust lands? office which operates the UST. (This is the contact person for the tank records.) <br /> 9 ❑Yes %No <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME ,/� 407. PHONE <br /> Vs aos. <br /> nr-� <br /> MA DIi O4DgS02EET ADDRESS L <br /> 409. <br /> CITY 410 <br /> /) P ny 1 TATE atl. ZIP 412. <br /> PROPERTY OWNER TYPE 1.CORPORATION 2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT O[:16.STATE AGENCY 413 <br /> �3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> III. TANK OWNER INFORMATION <br /> TANK QWNrVE'R NAME 414. PHONE <br /> 415 <br /> MAILING OR STREET ADDRESS <br /> 416. <br /> CITY 417. STATE 418. ZIP CODE <br /> 419. <br /> TANK OWNER TYPE U 1.CORPORATION ❑2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 420 <br /> M.PARTNERSHIP ❑5.COUNTY AGENCY [17.FEDERAL AGENCY <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY TK HQ 44- 1 1 1 1 -Call 916 322-9669 if questions arise <br /> 421. <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ❑1.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: 422. <br /> 3.INSURANCE ❑6.EXEMPTION ❑9.STATE FUND&CD <br /> VI. LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one box to indicate which address should be used for legal notifications and mailing. <br /> Legal notifications and mailings will be sent to the tank owner unless box 1 or 2 is checked. ❑ I.FACILITY C9 2. PROPERTY OWNER <br /> ❑3.TANK OWNER 423. <br /> VII. APPLICANT SIGNATURE <br /> Certification: I certify that the information provided herein is true and accurate to the best of my knowledge. <br /> S TURF OF APPLICANT DATE G 424, PHONE 425. <br /> E OF APPLICANT(print) 426. - �, _ <br /> TITLE OF APPLIC NT 427 <br /> S - Sf�NDh 0 w A)67 <br /> STATE UST FACILITY NUMBER(Agency use only) 428. 1998 UPGRADE CERTIFICATE NUMBER(Agency use only) 429. <br /> (See Data Element 1,above. <br /> UPCF Hwfwrc-a(1/99)-1/2 www.unidocs.org <br /> Rev.02/16/00 <br />