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C L :1ED PROGRAM CONSOLIDATED FO: ' TANKS -.. ✓ x *g.0 V(o 6ERGRO WD STORAGE TANI.5 - FAC TY(One page per site) _oT- TYPE OF ACTION1.NEW PERMIT ❑3.RENEWAL PERMIT ❑5.CHANGE OF INFORMATI�,,❑7•PERMANENTLY CLOSED SITE 400. (Check one item only) ❑4.AMENDED PERMIT (Specify change) L " ❑8.TANK REMOVED ❑6.TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION PRD Jam. - 4e Ob BUSINESS NAME(s.u F IUTY NAME or DBA-Doing Business As 5. FACILITY �Cll � I I H NEAREST CROSS STREET�J q un �a� rr 401. FACILITY OWNER TYPE 4.LOCAL AGENCY/DISTRICT• 402. / ��iIJ�J V ❑ 1.CORPORATION ❑5.COUNTY AGENCY* BUSINESS Lj 1.GAS STATION Ll 3.FARM COM ;4:2-INDIVIDUAL ❑6.STATE AGENCY- TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR ❑6.OTHER ❑3.PARTNERSHIP ❑7.FEDERAL AGENCY' TOTAL NUMBER OF TANKS 404. is facility on Indian Resmation 405• •If owner of UST is a public agency: name of supervisor of division.section or 406. REMAIN IN AT SITE or trust lands? office which operates the UST. (This is the contact person for the tank records.) / ❑Yes o II. PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407. PHONE 408. MAILING OR STREET ADDRESS 409 _13 S Sv.J c✓� CITY � 410. STATE 411. ZIP CODE 412. PROPERTY OWNER TYPE LJ E CORPORATION INDIVIDUAL 4.LOCAL AGENCY/DISTRICT U&STATEAGENCY 413. ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY M.TANK OWNER INFORMATION TANKOWNERNAME 414. PHONE Snell-✓�� i� �o �� a 6�I 415. MAILING OR STREET ADDRESS 416. CITY 417. STATE!/ 413. ZIP CODE S( �✓ (�' V" r �� O ` 119. TANK OWNER TYPE Lj 1.CORPORATION INDIVIDUAL Lj 4.LOCAL AGENCY/DISTRICT 0 6.STATE AGENCY 420. ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.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) ❑L SELF-INSURED ❑4.SURETY BOND ❑7.STATE FUND ❑ lo.LOCAL GOVT MEcfLA ism 422 ❑2.GUARANTEE [:15.LETTER OF CREDrT ❑t.STATE FUND&CFO LETTER ❑99.OTHER: ,Z1 INSURANCE ❑6.EXEMPTION ❑9.STATE FUND&CD VI.LEGAL NOTIFICATION AND MAILING ADDRESS Check one box to indicate which address should be used for legal notifications aad mailing. Legal ratifications and railings will be sent to the tank owner unless box I or 2 is checked. ❑ 1.FACILITY ❑2. PROPERTY OWNERS.TANK OWNER 423. VII.APPLICANT SIGNATURE Certification: I certify that the information provi'ed a in is U30.and accurate to the bat of my knowledge. SIGNATURE OF APPLICANT DATE424 PHONE425. v NAME OF APPLICANT(Qri _ /, 426. TITLE OF PLICANT 42z STATE UST FACILITY NUMBER(Agency use only) 423. 1998 UPGRADE CERTIFICATE NUMBER(Aacncy we only) 429. (See Data Element I,above. UPCF Hwfwrc-a(1/99)-1/2 bttp://snrw.unidocs.org Rev.02/16/00