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FIED PROGRAM CONSOLIDATED FO <br />TANKS` � � g. /I <br />UNDERGROUND STORAGE TANKS - FACILITY )ji <br />(One page per site) _. Page_of_ <br />TYPE OF ACTION ❑ 1. NEW PERMIT ❑ 3. RENEWAL PERMIT rat• CHANGE OF INFORMATION ❑ 7. PERMANENTLY CLOSED SITE 400. <br />(Check one item only) ❑ 4. AMENDED PERMIT (Specify change) [18. TANK REMOVED <br />[16. TEMPORARY SITE CLOSURE <br />I. FACILITY/SITE INFOILM <br />BUSINESS NAME IS.1a<FACa1Ty NAMEoroaA-oo,r,Eh,uaess ns) �. FACILITY <br />L/hdc�r 14a% 526 ID# <br />e <br />NEAREST C O SSTREET 401. FACB,TfY OWNER TYPE 4. LOCAL AGENCY/DISTRICT• wz. <br />❑ 1. CORPORATION E] 5. COUNTY AGENCY' <br />BUSINESS,141! GAS STATION 3. FARM ❑ 5. COMMERC*L, 03 2. INDIVIDUAL [16. STATE AGENCY* <br />TYPE ❑ 2. DISTRIBUTOR ❑ 4. PROCESSOR ❑. 6.OTHE ❑ 3. PARTNERSHIP ❑ 7. FEDERAL AGENCY* <br />TOTAL NUMBER OF TANKS <br />Is facility on Indian Reservation • If owner of UST is a public agency: name of supervisor of division, section or 405. <br />REMAINING AT SITE <br />or trust lands? office which opemres the UST. (This is the contactpenon for the tank records.) <br />❑ YesXNo <br />PROPERTY OWNER NAME <br />�Qh�G 407. 1 PZ6f ZiB"'v <br />MAILINGyR TREETADDRE S �o(F0 3�-583 409. <br />< Ze <br />S 3 (o <br />CITY n 410 <br />STATE 411 <br />ZIP�DE/ 411 <br />J S <br />PROPERTY OWNER TYPE Lj 1. CORPORATION JW2. INDIVIDUAL LI 4. LOCAL AGENCY / DISTRICT LI 6.. STATE AGENCY 413. <br />❑ 3. PARTNERSHIP [15. COUNTY AGENCY ❑ 7. FEDERAL AGENCY <br />p+� 9g <br />r <br />IM, <br />J rr rK <br />TANK OWNER NAME 414. PHONE 415, <br />MAILING OR ET ADDRESS 41a <br />CITY 417. <br />STATE ale. 1 ZIP CODE 419, <br />TANK OWNER TYPE ❑ 1. CORPORATION E 2. INDIVIDUAL El 4. LOCAL AGENCY/DISTRICT ❑.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) l l 44- Call 916) 322-9669 ,E questions arise 421. <br />'V. PETROLEUM UST FINANCIALRGSPONSIBILIT; - <br />INDICATE METHOD(s) ❑ 1. SELF-INSURED ❑ 4. SURELY 60ND ❑ 7. STATE FUND ❑ 10. LOCAL GOVT MECHANISM 4n <br />❑ 2. GUARANTEE ❑ 5. LETTER OF CREDIT r�0. STATE FUND & CFO LETTER ❑ 99. OTHER: <br />❑ 3. INSURANCE ❑ 6. EXEMPTION ❑ 9. STATE Flt ND & CD <br />VI. LEGAL NOTIFICATION AND MAILING ADDRESS ` <br />Check one box Us indicate ,Inch address should be used for Iclral rot) rcai o s and notling <br />Legal ratifications and standings will be scot to he tank owner unless box 1 ort is chocked ❑ I- FACII_ITY,<2. PROPERTY OWNER ❑ 3. TANK OWNER 43. <br />VII. APPLICANT SIGNATURE x "i <br />Certification: I certify Oat the Inrmidon provided heleiry true and actuate a the best of my knowledge. <br />SIGNATUREOF APP 7 <br />DATE 424. <br />/Z /3 L <br />PHONE Ce azs. <br />NAME OF APPLICANT (print) 4x5. <br />TITLE OF PLI ANT LJO � _3/ -.5:Ul 427. <br />/7 <br />STATE UST FACILITY NUMBER (Agency use only) 428. <br />1998 UPGRADE CERTIFICATE NUMBER (Agency useonly) 429. <br />(See Data Element I, above. <br />UPCF Hwfwm-a (1/99) -1/2 http://www.unidomorg Rev. 02/16/00 <br />