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FIED PROGRAM CONSOLIDATED <br /> ~� TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY Lk\ <br /> (One page per site) Page_of <br /> TYPE OF ACTION I.NEW PERMIT ❑3.RENEWAL PERMIT [15.CHANGE OF INFORMATION [17.PERMANENTLY CLOSED SITE <br /> (Check one item only) ❑4.AMENDED PERMIT (Specify change) [18.TANK REMOVED <br /> ❑6.TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION <br /> BUSINESS NAME(same as enauTV NAME or DSA-Doing Business As, >. FACILITY <br /> 1 S IDN <br /> NEA ST CROSS STREET \ 1. FACILITY OWNER TYPE Lj 4.LOCAL AGENCY/DISTRICT' 402. <br /> A-A-A-5 S �� �v� _P 1.CORPORATION ❑5.COUNTY AGENCY' <br /> BUSINESS t#1.GAS STATION Ll 3.FARM Ll 5.COMMERCIAL 403_ ❑2.INDIVIDUAL ❑6.STATE AGENCY' <br /> TYPE [12.DISTRIBUTOR ❑4.PROCESSOR ❑6.OTHER ❑3.PARTNERSHIP ❑7.FEDERAL AGENCY" <br /> TOTAL NUMBER OF TANKS 406- Is facility on Indian Reservation 405. •If owner of USE is a public agency:name of supervisor of division,section or 406. <br /> REMAINING AT SITE c� or trust lands? office which operates the UST. (This is the contact person for the rank records.) <br /> r <br /> 7 ❑Yes , INO <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME66). Eos. <br /> - NLP Xi,-I PJ7c( P PHONE NE <br /> MAILING OR STREET ADDRESS w9 <br /> CITY 410 1 STATE 411, ZIP CODE�7 -)- <br /> 412_ <br /> Lei 'i; nC0 <br /> PROPERTY OWNER TYPE ❑ L CORPORATION LJ2.11SDIVIDUAL Lj 4.LOCAL AGENCY/DISTRICT LJ6.STATEAGENCY 413_ <br /> ❑3.PARTNERSHIP [:15.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> III.TANK OWNER INFORMATION <br /> TAN WN R AME 414. PHONE 415. <br /> MAI ING OR STREET ADDRESS416. <br /> lA, ' (G _ zn cif? C,-i <br /> CITY 417 1 STATE 4;8. ZIP CODE 419 <br /> TAN'K/OWNERTYPE/1 CORPORATION El 2.INDIVIDUAL 4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 420_ <br /> �t[; G i 0/LL-L L.L(_. ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.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 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 El 5.LETTER OF CREDIT ja 8.STATE FUND&CFO LETTER El 99.OTHER: 422. <br /> [13.INSURANCE ❑6.EXEMPTION [19.STATE FUND&CD <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one bon 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. '5j L FACILITY ❑2. PROPERTY OWNER ❑3.TANK OWNER 423. <br /> VII.APPLICANT SIGNATURE <br /> Certification: I certify that the information provided herein is nue and accurate to the best of my knowledge. <br /> SIGNATURE OF APPLICANT DATE 424 PHONE 425. <br /> NAME OF APPLICANT(print) 426 TITLE OF APPLT 427. <br /> � I YI �1 l M R ICa^ <br /> STATE UST FACILITY NUMBER(Agency me only) 428, 1998 UPGRADE CERTIFICATE NUMBER(Agency use only) 429. <br /> (See Data Element 1,above. <br /> UPCF Hwfwrc-a(1/99)-1/2 http://www.unidocs.org Rev.02/16/00 <br />