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FIED PROGRAM CONSOLIDATED FORM PR q:FAGO14175 UNDERGROUND STORtHANGENF ANKS - FACILITY FAC q:FAOO-1zgl (one page persilel� LI I"n'v TYPE OF ACTION ❑ 1.NEWSITEPERMIT ❑3.RENEWAL PERMIT `/// (Check one rtem only) ((j INFORMATION ❑7.PERMANENTLY CLOSED SITE FJr_ 4.AMENDED PERMIT al aac mk ❑ B.TANK REMOVED ❑ SITE CLOSURLI.FACILITY/SITE INFORMATION 400 BUSINESSNAME(Seae es FACIpTY NAMEa DBA-Daiag 9aalneu ps) 620NSANJOAOUIKTONWOMENS CENTERFAc1urYPR B)q NEAREST CROSS STREET FA0014PRO518829 I FACll,ITY OWNER TYPE 40 ® I CORPORATION ❑4'LOCAL AGENCY/DISTRICT• BUSINESS ❑ 1 GAS STATION TYPE ❑;.FARM ❑5.COMMERCIAL ❑ 2.INDIVIDUAL ❑ 5.COUNTY AGENCY' ❑2.DISTRIBUTOR ❑4.PROCESSOR ❑b.STATE AGENCY- TOTAL NUMBER OF TANKS ❑b.OTHER 403 ❑ 3.PARTNERSHIP Is facility an Indian Reservation or ❑ 1 FEDERAL AGENCY- 402 REMAAIING AT SITE trustlarids7 •IfownerofEST is a public agency:name ofsupeMsorofdivision,section or office which operates the UST(This is the contact person for the tank records.) 04 ❑ Yes ® No Ops WOMENS CENTER 406 I1.PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407 PHONE MAILING OR STREET ADDRESS 408 CITY 409 410 STATE all ZIP CODE PROPERTY OWNER TYPE 412 ❑ I.CORPORATION ❑ 2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT El 3.PARTNERSHIP 1:15.COUNTY AGENCY El 6.STATE AGENCY Cl 7.FEDERAL AGENCY 413 III.TANK OWNER INFORMATION TANK OWNER NAME 414 PHONE MAILING OR STREET ADpRESS 13 CITY 416 417 STATE 416 ZIP CODE al9 TANK OWNER TYPE ❑ LCORPORATION ❑2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑ 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- Call(916)322-9669 if questions arise 421 V.PETROLEUM UST FINANCIAL RESPONSIBILITY INDICATE METHOD(s) ❑ I.SELF-INSURED ❑4,SURETY BOND ❑ 7.STATE FUND 0 10-LOCAL ❑2.GUARANTEE El 5.LETTER OF CREDIT El 8.STATE FUND&CFO LETTER El 99.OTHER GOVT MECHANISM 1:13.INSURANCE ❑6.EXEMPTION ❑ 9,STATE FUND&CD 422 V1.LEGAL NOTIFICATION AND MAILING ADDRESS Check one box to indicate which address should be used for legal notifications and mailing. Legal notifications and mailing will be sent to the tank owner unless box 1 or 2 is checked. ❑ ].FACILITY M 2.PROPERTY OWNER ❑3.TANK OWNER 423 VII.APPLICANT SIGNATURE Certification-1 certify that the infarmefion provided herein is true and accurate to the best of my knowledge. SIGNATURE OF APPLICANT DATE 434 PHONE 423 NAME OF APPLICANT(pi,,) 426 TITLE OF APPLICANT 422 STATE UST FACILITY NUMBER(Fe local as anh) 42a 1998 UPGRADE CERTIFICATE NUMBER IFer local aae oma) 429 Is 1998 Compliant? UPCF(1/99 revised)