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i 196, hilde <br />IFIED PROGRAM CONSOLIDATED FOIW I01 <br />TANKS I� <br />UNDERGROUND STORAGE TANKS - FACILITY <br />(One page per site) Page of J_ <br />TYPE OF ACTION . NEW PERMIT ❑ 3. RENEWAL PERMIT El 5. CHANGE OF INFORMATION [17. PERMANENTLY CLOSED SITE 400. <br />DP i <br />(Check one item only) El4. AMENDED PERMIT (Specify change) ❑ 8. TANK REMOVED <br />[16. TEMPORARY SITE CLOSURE <br />I. FACILITY/SITE INFORMATION <br />BUSINESS NAME(Same as FACI=NAMB or DBA- Doing Business As) 3. FACILITY <br />tN IDn F 0 0 0 S g 1 <br />3 K o <br />NEAREST CROSS STREET 4oi. FACILITY OWNER TYPE ❑ 4. LOCAL AGENCY/DISTRICT- 402. <br />0ma R I. CORPORATION ❑ 5. COUNTY AGENCY - <br />BUSINESS 0;'CGAS STATION ❑ 3. FARM ❑ 5. COMMERCIAL 401 ❑ 2. INDIVIDUAL ❑ 6. STATE AGENCY* <br />TYPE ❑ 2. DISTRIBUTOR ❑ 4. PROCESSOR ❑ 6. OTHER ❑ 3. PARTNERSHIP ❑ 7. FEDERAL AGENCY* <br />TOTAL NUMBER OF TANKS 404. <br />facility on Indian Reservation 405. <br />* If owner of UST is a public agency: name of supervisor of division, section or 406. <br />REMAINING AT SITE <br />tis <br />or trust lands9 <br />office which operates the UST. (This is the contact person for the tank records.) <br />6sjyrs <br />Yes [t3'iQo <br />[]Yes <br />II. PROPERTY OWNER INFORMATION <br />PROP TY OWNER NAME 407. <br />��ES <br />PHONE 408. <br />gif �D3"SpLG <br />2c L Sr S`SnciAn�£i <br />MAILING OR STREET ADDRESS M109' <br />41s k%t4-i PiV4,"4b I- <br />CITY 410. <br />STATE 411. ZIPCODE 412. <br />ETA/D 1 <br />AW 'nf-d <br />PROPERTY OWNER TYPE . CORPORATION -E]2. INDIVIDUAL ❑ 4. LOCAL AGENCY / DISTRICT ❑ 6. STATE AGENCY 413. <br />❑ 3. PARTNERSHIP ❑ 5. COUNTY AGENCY ❑ 7. FEDERAL AGENCY <br />III. TANK OWNER INFORMATION <br />TANK OWNER NAME 414, <br />PHONE 415. <br />�a.>7�s McQaaG /otiR%�$ <br />1 ice'- n -S�c2G <br />MAILING OR STREET ADDRESS 416 <br />I-AAlir <br />CITY 417. 1 <br />STATE 418. <br />ZIP CODE 419. <br />914S -O) <br />le"61 <br />A) <br />TANK OWNER TYPE Lei. CORPORATION ❑ 2. INDIVIDUAL ❑ 4. LOCAL AGENCY/DISTRICT 6. STATE AGENCY 420. <br />❑ 3. PARTNERSHIP ❑ 5. COUNTY AGENCY [17. FEDERAL AGENCY <br />IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br />TY I I I Call 916 322-9669 if guestions arise 421. <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br />INDICATE METHOD(s) ❑ 1. SELF-INSURED ❑ 4. SURETY BOND ❑ 7. STATE FUND [110. LOCAL GOVT MECHANISM 422 <br />[STATE FUND & CFO LETTER [199. OTHER: <br />❑ 2. GUARANTEE ❑ 5. LETTER OF CREDIT <br />[13. INSURANCE [16. EXEMPTION 0 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 mailing. <br />Legal notifications and mailings will be seat to the tank owner =less box 1 or 2 is checked ❑ L FACILITY PROPERTY OWNER ❑ 3. TANK OWNER 423. <br />VII. APPLICANT SIGNATURE <br />Certification: I certify that the information provided herein is Luc and accurate to the best of my knowledge. <br />SIGNA RE OFA ANT <br />DA 424. PHONE 4zs. <br />NAM OF APPLIC (print) 426. <br />TITLE OF APPLICANT 4zz <br />. Hitrziiv dl <br />.e T <br />STATE UST FACILITY NUMBER (Agency use only) 429. <br />1998 UPGRADE CERTIFICATE NUMBER (Agency use only) 429 <br />(See Data Element 1, above. <br />UPCF Hwfwrc-a (1/99) -12 www.unidocs.org Rev. 02/16/00 <br />