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r - <br /> UP� ED PROGRAM CONSOLIDATED FOM <br /> CrATANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY q�0- <br /> 5 (one page per site) <br /> Pape _ of _ <br /> TYPE OF ACTION r 1.NEW SITE PERMIT r 3.RENEWAL PERMIT r 5.CHANGE OF INFORMATION(Specify change- 7.PERMANENTLY CLOSED SITE <br /> (Check Modern only) <br /> r 4.AMENDED PERMIT lora/use only) rS.TANK REMOVED 400 <br /> r 6.TEMPORARY SITE CLOSURE <br /> I.FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Same as FAC LITY NAME or DBA-Doing Business,As) 3 FACILITY 1013 <br /> EILI- ol- GWAtse ' C,NDAJ. J FfhJUl3913 <br /> NE.ApREST CROSS STREET 401 G FACILITY OWNER TYPE <br /> f A FIIC ST Ret g5e2 r 1. CORPORATION <br /> <. LOCAL AGENCY/DISTRICT' <br /> BUSINESS TYPE r 1.GAS STATION r 3.FARM r 5.COMMERCIAL �2. INOMDUAL r 5. COUNTYAGENCY' <br /> r <br /> r 2.DISTRIBUTOR r 4 PROCESSOR 6.OTHER r 3. PARTNERSHIP 6. STATEAGENCY- <br /> 3 r 7. FEDERAL AGENCY- 402 <br /> 40 <br /> TOTAL NUMBER OF TANKS Is reality on Indian Reservation ar If owner <br /> d UST a a puolic agency:name of supervisor or <br /> REMAINING AT SITE (outlands? division,sachon or afire which operates the UST. <br /> 04 (This is the contaC person for du tank records) <br /> 4 <br /> r Yes r No 405 406 <br /> It.PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408 <br /> 'Dptvt0 Al,%10 MRWA'N 6 wAptwfcv_ <br /> �o� -sirs- 989 9 <br /> MAILING OR STREET ADDRESS 409 <br /> CITY 910 STATE 411 ZIP GOD 412 <br /> 5N5A?J1A Vill ICA I9 S yo <br /> PROPERTY OWNER TYPE . INDIVIDUAL r 4. LOCAL AGENCY/DISTRICT r 6. STATEAGENCY 413 <br /> r 1. CORPORATION r 3. PARTNERSHIP r S. COUNTYAGENCY r 7. FEDERALAGENCY <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> DAvlc c,Np KA NNS W w%c4tc moi-syr-5e� a <br /> MAILING OR STREET ADDRESS 416 <br /> 5*30 lactOu GTr VideLL&V, Rzoll <br /> CITY 417 STATE 418 ZIP CODE 419 <br /> S,q,it., CA, 9514044 <br /> TANK OWNER TYPE Y-2, INDIVIDUAL r 4. LOCAL AGENCY/DISTRICT r 6. STATEAGENCY 420 <br /> r 1. CORPORATION [ 3. PARTNERSHIP r S. COUNTYAGENCY r 7. FEDERALAGENCY <br /> TY(TK)HO 4 4 Call(916)322-9669 if questions arise 421 <br /> INDICATE METHODS) r 1. SELF-INSURED r 4. SURETY BOND r 7. STATE FUND r 10. LOCAL GOV=T MECHANISM <br /> r 2. GUARANTEE r S. LETTER OF CREDIT r B. STATE FUND 8 CFO LETTER r 99. OTHER <br /> r 3. INSURANCE r 8. EXEMPTION r 9. STATEFUNDa CD 422 <br /> Check we boa to indicate which address should beused far legal notRcatians and mailing. r 1. FACILITY �Cz. PROPERTY OVrNER r 3. TANK OWNER 423 <br /> al n t6 ations and maili s will be sent to the tank owner unless box 1 or is crerkeo. <br /> Certification: [can that the information pravoW herein is We and accurate to Ne best of my,o 9,g9. <br /> SI TUfjEOF LI ANT - DATE `424 PHONE 425 <br /> spa ez 204- y--os�B <br /> NAME OF APPLICANT(print 426 TRLE OFAPPLICANT4 7 <br /> M 140-Crl (VE EN✓till Ac 6w risii 57u t <br /> STATE UST FACILITY NUMBER(For/ocal use only) 42B 1998 UPGRADE CERTIFICATE NUMBER(For local use omy) 429 <br />