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ED PROGRAM CONSOLIDATED FO 2 2-710=4f UNDERGROUND STORAGE TANKS - FAC IT a 8(t) � 0 �f (One page per site) Page_of TYPE OF ACTION fig 1.NEW PERMIT ❑3.RENEWAL PERMIT ❑5.CHANGE OF INFORMATION ❑7.PERMANENTLY CLOSED SITE 00. (Check one item only) ,` ❑4.AMENDED PERMIT (Specify change) MO ED I t q ❑6.T PORAR SITE CLO f y I t f F7 tZv Z f N t A-C,i (Z. t F I. FACILITY/SITE INFORMATION 1< <W g 0� BUSINESS NAME(Saaeu FACILITY NA «DBA-Wing Bmin«s As) 3. FACILITY zD fTi� >r 9D1 IsDc( I I I I IL NEAREST CROSS STREET 401, FACILITY OWNER TYPE LJ 4.LOCAL AGENCY/DISTRICT- 402. Al.CORPORATION ❑5.COUNTY AGENCY- BUSINESS 0 I.GAS STATION LI 3.FARM 5.COMMERCIAL 496. ❑2.INDIVIDUAL ❑6.STATE AGENCY- TYPE ❑2.DISTRIBUTOR [14.PROCESSOR [16.OT14ER ❑3.PARTNERSHIP ❑7.FEDERAL AGENCY- TOTAL NUMBER OF TANKS °04 Is facility on Indian Reservation 405. -if owner of UST is a public agency:name of supervisor of division section or 4% REMAINING AT SITE or trust lands? office which operates the UST. (This is the contact person for the WA records.) ❑Yes No X0 II. PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 497. P ONE 409. 1 % eZ0 G -Z MAILIN STREDRESS 409. E3o 3 CITY 410. 1 STATE 411. 1 ZIP CODE 412. 57 PROPERTY OWNER TYPE ^7ORPORATION .INDIVIDUAL Lj 4.LOCAL AGENCY/DISTRICT Lj 6,STATE AGENCY 412. ❑3.PARTNERSHIP [15.COUNTY AGENCY [17.FEDERAL AGENCY M.TANK OWNER INFORMATION TANK WNER CME I / ^ it Mc 414. PHON�� V 416. MAILIN STREET ADDRESS / �J G °lb. CITY G/1-. 417. STATE us. ZIP CODE 419. S �l0 oa,J �s TANK OWNER TYPE CORPORATION 2.INDIVIDUAL 0 4.LOCAL AGENCY/DISTRICT LJ6.STATEAGENCY 420. ❑3.PARTNERSHIP E15.COUNTY AGENCY [17.FEDERAL AGENCY IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY TK HQ 44- 1 1 1 1 1 1 1 Call 916 322-9669 if questions arise 421 V.PETROLEUM UST FINANCIAL RESPONSIBILITY INDICATE METHOD(s) ❑1.SELF-INSURED ❑4.SURETY BOND ❑7.STATE FUND ❑10.LOCAL GOVT MECRA.VSM 422 ❑2.GUARANTEE ❑S.LETTER OF CREDIT ❑S.STATE FUND&CFO LETTER ❑99.OTHER: PJ.INSURANCE ❑6.EXEMPTION ❑9.STATE FUND&CD v VI.LEGAL NOTIFICATION AND MAILING ADDRESS Check one box to indicate which address should be used for legal notifications and railing. �J1� Legal nodficatinm and mailings will be sent m the tank owner unless box l or 2 is cbecked. ❑ I.FACILITY ❑ )C!2. PROPERTY OWNER 3.TANK OWNER 423. VII.APPLICANT SIGNATURE Certification: I certify Out a inforn nation pm ' ed heroin is and accurate m the best of my knowledge. SIG TO AP ICANT DATEpL 424. PHONE 5425 � O NAME OF ACA T(print) 1$6 TITLE 0 APPL[ ANT a21 STATE UST FACILITY NUMBER(Agency me only) 423. 1998 UPGRADE CERTIFICATE NUMBER(Agencyase«y) 429. (See Data Element I,above. UPCF Hwfwrc-x(1/99)-1/2 httpd/w mt.unidoes.org Rev.02/16/00