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U W@IED PROGRAM CONSOLIDATED F RM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page per site) <br /> �.� Page _ of _ <br /> TYPE OF ACTION r 1.NEW SITE PERMIT T 3.RENEWAL PERMIT 1V 5.CHANGE OF INFO♦R✓MA OLJ(Specify change- r 7.PERMANENTLY CLOSED SITE <br /> (Check one item only) local use only)1�rA l IT.'(/�.'r 1 D✓1 F &TANK REMOVED 400 <br /> r 4.AMENDED PERMIT <br /> r 6 TEMPORARY SITE CLOSURE <br /> I.FACILITY I SITE INFORMATION <br /> BUSINESS NAME(Same as FACILITY NAME or OBA-Doing Business As) 3 FACILITY to <br /> ,us YS��cn IlJ C <br /> N ESTCROSSBTRE'E/T p 401 FACILITY OWNER TYPE r 4. LOCAL AGENCY/DISTRICT' <br /> 70-7RQ P{� 1` (FsG Y . CORPORATION r 5. COUNTYAGENCY' <br /> BUSINESS TYPE F 1.GAS STATION T 3.FARM 5.COMMERCIAL T 2. INDIVIDUAL <br /> ENCY- <br /> r 2 DISTRIBUTOR T 4 PROCESSOR r 6 OTHER r 3. PARTNERSHIP r 6. FEDESTATRAL <br /> AL AGENCY' <br /> r 7. FEOEBAL AGENCY' 402 <br /> 403 <br /> TOTAL NUMBER OF TANKS Is farJlity on Indian Reservation or 'It owner of UST is a public agency:name of supervisor of <br /> REMAINING AT SITE Irustlantls7 division,section or office,which operates Ne UST. <br /> / (This is the contact person for the tank records.) <br /> 404 r Ye, IMO 405 406 <br /> It.PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408 <br /> Siwe w ILu4K4S Sol 623 y000 <br /> MAILING OR STREET AODRESS 409 <br /> S 7AIM-609r2D cN Co# 99,o <br /> CITY 410 STATE 411 ZIP CODE 412 <br /> TREQCv t( c4w)o 1 644 95-23/ <br /> PROPERTY OWNER TYPE ,../ r 2. INDIVIDUAL r 4. LOCAL AGENCY/DISTRICT T 6. STATEAGENCY 413 <br /> 1'-1. CORPORATION r 3. PARTNERSHIP r 5. COUNTYAGENCY r L FEDERALAGENCY <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> ,mss sus9Y <br /> MAILING OR STREET ADDRESS 416 <br /> ?O7Igor-H RD <br /> CITY STATE 418 ZIP CODE 419 <br /> f . 417 # c 1/� 95-2 3 <br /> TANK OWNER TYPE __/ T 2. INDIVIDUAL T 4. LOCAL AGENCY/DISTRICT r 6. STATE AGENCY 420 <br /> Y 1. CORPORATION r 3. PARTNERSHIP r 5. COUNTY AGENCY r 7. FEDERAL AGENCY <br /> TY(TK)HQ 4 4 Call(916)322-9669 if questions arise 421 <br /> INDICATE METHOD(S) 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 W. STATE FUNDS,CFO LETTER r 99. OTHER: <br /> T 3. INSURANCE r 6 EXEMPTION r 9. STATE FUND S,CD 422 <br /> Cheri one box to indicate which address should be used for legal notifications endmei ling. r 1. FACILITY T 2. PROPERTYOWNER3. TANK OWNER 423 <br /> Li al no44ications and mailings will ba sent to the tank owner u less x 1 or is checked. <br /> Certification I cemty that the information provided herein is We and accurate to the best of my knowledge. <br /> SIGNATURE OFA�PLI(�A 424 PHONE 425 <br /> NAME OF APPLICA (pnn(, j"[-Qtgt^ <br /> NT426 TITLE OF APPLICANT 427 <br /> u�rc�v� tem ICORE *1 <br /> STATE UST FACILITY NUMBER(For/ocel use only) 428 1998 UPGRADE CERTIFICATE NUMMM-Bj,EERR((For Aoal use only) 429 <br /> V V <br /> UPCF(1/99 revised) 5 Formerly SWRCB Form A <br />