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UswK.IED PROGRAM CJNSOLIDATED FOR, 22 0 TANKS DERGROUND STORAGE TANKS - FACILITY ' (One page per site) page_of TYPE OF ACTION &1.NEW PERMIT [13.RENEWAL PERMIT (Check one item only) ❑5.CHANGE OF INFORMATION ❑7.PERMANENTLY CLOSED SITE � Y) ❑4.AMENDED PERMIT (Specify change) ❑S.TANK REMOVED ❑6.TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATIONo2�e ©� BUSINESS NAME(SWwFUTY NAME or DBA-Doing Butineu As y. FACILITY Z_ 1. NEAREST CROSS STREETg9 a NCY/DISTRICT• X02. ytV) 401. FACILITY OWNER TYPE 4.LOCAL AGE ��V�� un {�l Y ❑ I.CORPORATION ❑5.COUNTY AGENCY• BUSINESS U 1.GAS STATION U 3.FARM COMMERCIAL 4o3. Q�_INDIVIDUAL [16.STATE AGENCY* TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR [16.OTHER ❑3.PARTNERSHIP ❑7.FEDERAL AGENCY" 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. REMAIN N AT SITE or trust lands? oMce which operates the UST. (This is the contact person for the tank records.) ❑Yes ANO /// II. PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407. PHONE 408. t1/1J/0 MAILING OR STREET ADDRESS 409. CITY J10 STAT 411 ZIP CODE 4tZ O � PROPERTY OWNER TYPE I.CORPORATION INDIVII 1 14.LOCAL AGENCY/DISTRICT Lj 6.STATE AGENCY 413. ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY III.TANK OWNER INFORMATION TANKOWNERNAME 414. 1 PHONE , 415 MAILING OR STREET ADDRESS 416. CITY ��,� 417. STAT G�9 41a. ZIP CODE O 419. -5- s� TANK OWNER TYPE LJ 1.CORPORATION INDIVIDUAL 4.LOCAL AGENCY/DISTRICT U&STATEAGENCY 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) ❑1.SELF-INSURED ❑4.SURETY BOND ❑7.STATE FUND ❑ 10.LOCAL GOVT MECIRA,YIsm. ❑2.GUARANTEE [15.LETTER OF CREDIT ❑8.STATE FUND&CFO LETTER ❑99.OTHER: 422. 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 and trsaaling. Legal notifications and tailings will be sent to the tank owner unless box l or 2 is cbeeked. ❑ 1.FACILITY ❑2. PROPERTY OWNER" 3.TANK OW 1ER 423. VII.APPLICANT SIGNATURE Certification: I certify that the information proriaed a in is true,and accurate to the lest of my knowledge. SIGNATURE OF APPLICANT DATE 424. PHON 425. NAME OFAPPL ANT(pri1�, /� 426. TITLE OF APPLICANT 427. STATE UST FACILITY NUMBER(Agency we only) 421 1998 UPGRADE CERTIFICATE NUMBER(Agency we onry) 429. (See Data Element I,above. UPCF Hwfwrc-a(1/99)-1/2 h"p://nrw.unidocs.org Rev.02/16/00