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�IFIED PROGRAM CONSOLIDATED f� <br /> �,, O�;ANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> OMPageYC _ ofTYPE OF ACTIONI4LNEW SITE PERMIT ❑ 3.RENEWAL PERMIT ❑ S.CHANGE OF INFORMATION(Speary durrga- ❑ ].PERMANENTLY CLOSED SITE 1 <br /> (Cflecs one aeon'my) T <br /> C1 4AMENDED PERMIT kW use on, ❑ 8.TANK REMOVED <br /> . <br /> 138.TEMPORARY SITE CLOSURE <br /> I.FACILITY/SITE INFORMATION n' <br /> BUSINE55 NAME(Same as FACILITY NAME or Bk-Dong 84jilreal 3 FACILITY IDs 1 A <br /> FI b O t5 1 <br /> NEAREST CROSS STREETL' 401 FACILITY OWNER TYPE ❑ 4. LOCAL AGENCYITNSTNIC" <br /> r1 l , 1 C-' p IN 1. CORPORATION 11 5. COUNTYAGENCW <br /> BUSINESS ` of I El 2. iNDMWAI ❑ 6. STATEAGENCY• <br /> TYPE yr 1.GAS STATION ❑ 3.FARM ❑ 5.COMMERCIAL ❑ 3. PARTNERSHIP ❑ ]. FEDERAL AGENCY' 40t <br /> ❑ 2.DISTRIBUTOR El 4.PROCESSOR C16.OTHER 403 <br /> TOTAL NUMBER OF TANKS Is foamy on Indian Reservation or 'If owner of UST a ouo4c n.e ..name of woanasor of <br /> REMAINING AT SITE IruMaMsi dmalon.section or omca emldl odaralas me UST. <br /> 404 (This,."conlxi Person fw me Urtk monms.) <br /> ❑Yee IF.No 606 406 <br /> II.PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 406 <br /> SA � r� r� �y 3--3�7 <br /> RWLING-ORSTREETADMESSS t/ � 409 <br /> rY7�.�/1`Vp V y 410TATE 411 LP 412 <br /> S Cit �sao � <br /> PROPERTY OWNER TYPE ,., // C32. INDIVIDUAL ❑ 4. LOCAL AGENCY/DISTRICT 116. STATE AGENCY 413 <br /> LY�T. CORPORATION 3 PARTNERSHIP ❑ 5. COUNTY AGENCY ❑ 7. FEDERALAGENCY <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAMEI I 414 PHONE <br /> 212 <br /> MAILING OR STREET ADDRESS `/ YV V 416 <br /> CITY 417 STAT 416 LPC7a 419 <br /> TANK OWNER TYPE �- ❑ 2. INDIVIDUAL ❑ 4. LOCAL AGENCY/DISTRICT 1:16 STATEAGENCY 420 <br /> P-1 CORPORATION 13 3 PARTNERSHIP ❑ S. COUNTYAGENCY ❑ 7. FEDERALAGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 4 4 Call(916)322-9669 H questions ansa 421 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHODS) C3 1 SEIF-INSURED ❑ 4. SURETY BOND ❑ 7. STATE FUND ❑ 10. LOCALGCVTMECHANISM <br /> ❑ 2. GUARANTEE ❑ 5. LETTER OF CREDIT Cl B. STATE FUND&CFO LETTER ❑ 99.OTHER: <br /> INSURANCE ❑ e. EXEMPTION Cl 9. STATEFUND&CO 422 <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one box to indicate which address should be used for"at notifications and mailing. ❑ 1. FACILITY . PROPERTY OWMER ❑ 3. TANK OWNER 423 <br /> Legal notifications and mailings wil W Ism to Ne lank charter unless box 1 or 2 is crashed. <br /> VII.APPLICANT SIGNATURE <br /> Ce tlaon I M t Ne h6rdh <br /> Pmwdad Haran a we ane aoatmle to the beet of my knawledga. <br /> 6 NATUR P NT E 421 PHON 425 <br /> DATE i d s3 -ag <br /> NAII OF A3P ,11CANT(piny 426 TITLE OFAPPLICANT 427 <br /> STATE UST FACILITY NUMBER(Fbrldcal use omy) 428 1990 UPGRADE CERTIFICATE NUMBER(Far local use only 429 <br /> UPCF(1/99) - ' l - Forrrlery SMCB FormA <br />