Laserfiche WebLink
o �'p il�7.b�6� ✓Zvh <br /> " IFIED PROGRAM CONSOLIDATED FORM /dxllt��9l <br /> TANKS JUNDERGROUND STORAGE TANKS - FACI <br /> (One page per site) Page zof <br /> TYPE OF ACTION NEW PERMIT ❑3.RENEWAL PERMIT ❑S.CHANGE OF INFORMATION ❑7.PERMANENTLY CLOSED SITE 400. <br /> (Check one item only) ❑4.AMENDED PERMIT (Specify change) ❑9.TANK REMOVED <br /> ❑6.TEMPORARY SITE CLOSURE 8 t <br /> 2 ` <br /> I. FACILITY/SITE INFORMATION 0 ? V-36 r 'moo <br /> BUST BSSNAME(SameasFACILITYNAMEorDBA-DoingBusinessAs) 7. FACILITY <br /> lk <br /> �LD� - T!><7� IDR tW / <br /> NEAREST CROSS STREET 4a1. FACILITY OWNER TYPE U 4.LOCAL AGENCY/DISTRICT' 402. <br /> j ❑ 1.CORPORATION ❑5.COUNTY AGENCY' <br /> BUSINESS 1.GAS STATION LJ 3.FARM .COMMERCIAL 403. INDIVIDUAL [16.STATE AGENCY' <br /> TYPE ❑2.DISTRIBUTOR [14.PROCESSOR ❑6.OTHER ❑3.PARTNERSHIP [17.FEDERAL AGENCY' <br /> TOTAL NUMBER OF TANKS 404. Is facility on Indian Reservation 405. 'If owner of UST is a public agency: name of supervisor of division,secdon or 406. <br /> REMAINING AT SITE /� ) or trust lands'r once which operates the UST. (This is the contact person for the tank records.) <br /> ( / ❑Yes o <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 4as. <br /> 4�7- <br /> i7 /fo C /j I7 S <br /> MAILING OR STREET ADDRESS 409. <br /> CITYC/�' -� 410. STATE r 411. ZIP CODE ��® -� °lx. <br /> 2 1P <br /> PROPERTY OWNER TYPE 1©.CORPORATION .INDIVIDUAL Lj 4.LOCAL AGENCY/DISTRICT 6.STATE AGENCY 413. <br /> ❑3.PARTNERSHIP [15.COUNTY AGENCY [17.FEDERAL AGENCY <br /> III.TANK OWNER INFORMATION <br /> TANKOWNERNAME 414. PHONE D 415. <br /> � S <br /> MAILING OR STREET ADDRESS 416, <br /> © L <br /> CITY 417. STATE 419. ZIP CODE 419. <br /> c4l . �Z o '" c319 to <br /> TANK OWNER TYPE 1.CORPORATION 2.INDIVIDUAL Lj 4.LOCAL AGENCY/DISTRICT Li 6.STATE AGENCY 420. <br /> ❑3.PARTNERSHIP [15.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY TK H 44- Call 916 322-9669 if questions arise 421. <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) .SELF-INSURED ❑4.SURETY BOND ❑7.STATE FUND [110.LOCAL GOVT MECHANISM 422 <br /> 2.GUARANTEE [IS.LETTER OF CREDIT [IS.STATE FUND&CFO LETTER ❑99.OTHER: <br /> ❑3.INSURANCE ❑6.EXEMPTION ❑9.STATE FUND&CD <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one box to indicate which address should be used for legal notifications and moiling. <br /> Legal notifications and mailings will be sent to the tank owner unless box t or 2 is checked ❑ 1.FACILITY ❑2. PROPERTY OWNER A TANK OWNER 421 <br /> II <br /> V .APPLICANT SIGNATURE <br /> Certification: I certify Pt the info t n provided herein is truc and accurate to the best of my knowledge. <br /> SIGNATUREOF PLICA DATE 024PHONE °zs. <br /> /D a6 3 73DS <br /> NAME OF APP ANT p' t) 426. TITLE OF APPLICANT an. <br /> p SD<a/ <br /> STATE UST FACILITY NUMBER(Aseney use only) 429. 1996 UPGRADE CERTIFICATE NUMBER(Agency ase only) 4z9. <br /> (See Data Element 1,above. <br /> UPCF Hwfwrc-a(I/99)-112 http:/[%is .unidocs.org Rev.02/16/00 <br />