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MAY-03-2005 02 :37 PM RAH ENVIRONMENTAL INC 91602 8955 P. 09 <br /> • <br /> UMFTED PROGRAM CONSOLIDATED FORM /j1�lOVj TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (mc page per site) Page I/ <br /> or I <br /> TYPE OF ACTION I.NEW SITE PERMIT [13.RENEWAL PERMIT D S.CHANGE OF INFORMATION �❑/7.PERMANENTLY CLOSED SITE <br /> ehanga local m¢only M L TANK REMOVED <br /> (Cheek oM item only) ❑e.AMENDED PERMIT- mccify '` <br /> ❑6.TMAMRARY SITE CLOSURE ace <br /> I. FACILITY/SITE INFORMATION <br /> BUSIN SrAMEi 1AaurymAMa a DSA-06as a�A.t FACILITY IDS I <br /> I, I LjLj 4.LOCAL GENCY/DISTRICT• <br /> NEA TC §SSTyR£ qt FACILITYOWNER TYPE <br /> 1 o [3x I.CORPORATION s.COUNTY AGENCY* <br /> Yd <br /> 6.STATE AGENCY* <br /> BUSINESS L GAS STATION J.FARM S. COMMERCIAL ❑ 2.INDIVIDUAL ❑7 FEDERAL AGENCY' w2 <br /> ❑ L PARTNERSHIP ❑ <br /> TYPE [3 2.DISTRIBUTOR ❑4•PROCESSOR❑6. OTHER °� -ITawnerat UST its FWiia ageay:nates ofsayervewr oPdivisiaa section or oll-me.he! <br /> TOTAL NUMBER OF TANKS Is facility a a Indian Rcsesvation or p�d.UST CrW E tb,w,,,,,pnon flof the yak reeoIdL) <br /> REMAINING AT SITE Sosclands7 am <br /> a. ❑ Yes No ate <br /> R. PROPERTY OWNERINFORMATION <br /> PROPER OWNER INA <br /> 41/Y <br /> C_ ib a <br /> MAI z4o9 S(1.4'4119- l <br /> MM .,o STATE a 717 CODE <br /> CITY �,5355 u <br /> PROPERTYa 0 TYPE I.CORPORATION 2.INDIVIDUAL Lj`4.LOCAL AGENCY/°(STRICT 6 STATE AGINCY at' <br /> ❑I.PARTNERSHIP 05.COUNTYAGENCY O7 FEDERAL AGENCY <br /> III.TANK OWNER INTORTYIATION <br /> ,t. PHONE .Is <br /> TANKO ENAM <br /> fVIC, to �I <br /> MAILING R� D Sw4Q 12A <br /> Z N1 an STA ns ZIP co E-� •19 <br /> CffY �� 4.LOCAL AGENCY/OLSTRICT 6.STATE AGENCY m <br /> TAN55 <br /> KOWNEA TYPE 1.CORPORATION 2.INDIVIDUAL <br /> 3.PARTNERSHIP Q S.COUNTI'AGENCY Q 7.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY HQ 44 Call 916 322-9669 if pestions arise <br /> nl <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(:) (] I.SELF-INSURED ❑4.SURETY BOND [17.STATE FUND l 3 10.LOCAL GOVT MECHANISM <br /> ❑3. rqq.OTHER, <br /> GUARANTEE <br /> UARATINSURANCE ❑6.EXEMPTION <br /> LETTER <br /> OFCREDR 0 9.STATE FUND&CD S.STATE FUND&CFO LETTER .�. m <br /> vI LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one bo:m imiatc+4ieh addta shoWd be used fisr kpl tgdfintitsm and nviliui L PROPERTY OWNER ❑7.TANK OWNER w <br /> Lepl notirmtioro and milia r 116.saa m die w*ownee mien bot 1 a r o checked ❑ 1.FACILITY ... <br /> VII.APPLICANT SIGNATURE R 0030 <br /> cm1i.m.-I...tiy dnt Ne inronnadoo Fso+ided herein is ova and ucrosm m the best army kn"kdaa W PHO N .ZS <br /> FAPPL ANT DATE �5 1/h 777 <br /> LIC m) a36 TITLE OF APP l ANT p <br /> ' r �iOYZ 7dt"dYVN�f" <br /> STATE US FACIL NUMBER IF«**--IT) "=a 1998 UPGRADE . TIFICATE NUMBER(Fo mlme tell <br /> 171 - Follnefly SWRCB Form fi <br />