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• V V ' <br />. NYIPIED PROGRAM CONSOLIDATED F 2,6 rQ-0S'. !C a� <br />TANKS <br />UNDERGROUND STORAGE TANKS - FACILITY <br />(0- Paso Por ate) Par _ ot'_ <br />TYPE OF ACTION yJ I. NEW PE RIOT ❑ 3. RBNHWAL PMUaT 751CHANGE OF INFORMATTON ❑ 7. PERMANENTLY CLOS® SITS � <br />(Check dm Rem ody) ❑ 4.= PERMTI (Speedy chge) ❑ 8.7ANK RHMOV® <br />❑ 6. TEMPORARY S[TH CIASORB <br />L FACIIdTY/SITE INPORMATION <br />BUSNAME(s.err FACLlry HAkEmDBA-n.,;ag a.�.. A.) 1. FACILITY <br />LIN4CA1 YrIIkRILt-moi F A U (� � 3,5 el I <br />NEAREST CROSS STREET wt. FACIIdTY OWNER TYPE 4. LOCAL AGENCY/Disnucr, 4a2 <br />❑ 1. CORPORATION ❑ 5. COUNTY AGENCY* <br />BUSEdESS 1. GAS STATION 3. FARM S. COM fE RCLAL dm. la 2 INDIVIDUAL ❑ 6. STATE At;ENCY, <br />TYPE ❑ 2. DSTRIBUTOR ❑ 4. PROCESSOR ❑ 6.OTTffR ❑ 3. PARTNEIL4Rp ❑ 7. FEDERAL AGENCY, <br />TOTAL NUMBER OF TANKS 404. <br />REMAINING AT SITE <br />L hoHAy m Indian Re atim 401. <br />m had land,? <br />�E o.m m UST a a P m .gamy n of aupmvor of mviaioq action ar 406 <br />oBwe whichopentr the UST. (Thee the cora peon for the tmk maf&.) <br />❑ Ya ®No <br />IL PROPERTY OWNER INFORMATION <br />PROPERTY -OWNER NAME PHONE <br />wg <br />rn I 209 531- �I(S <br />MAIL,W OR STREET ADDRESS <br />72-03 E Hwl Z(p 10. <br />CITY STOC KTa AI 41¢ <br />J <br />STATE ^N 41t. <br />L,f't <br />ZIPCODE <br />9 5 zo 6 "Z <br />PROPERTY OWNER TYPE CILCORPORATTON 2 I DIVIDUAL U 4. LOCAL AGENCY/ DISTRICT 6. STATE AGENCY 413. <br />❑ 3. PARTNIILSfIIP ❑ 5. COUNTY AGENCY ❑ 7. FEDERAL AGENCY <br />IDL TANK OWNER INFORMATION <br />TANK OWNER NAME A Ih A 12.T -t r 51 N G H 414. <br />PHONE 415. <br />2,aq 931 -Sy8-7 <br />MAILING OR STREET ADDRESS <br />87-03,5' HWy 2- (o 416 <br />CITY sTbC.K..•rz" 417. <br />STATE 418. ZIPCODE 419. <br />95zo b <br />TANK OWNER TYPE ❑ 1. CORPORATION 0&2 AIDIVIDUAL ❑ 4. LOCAL AGENCY/DISTRICT ❑ 6.3TATE AGENCY <br />4M <br />3. PARTNERSHIP 5. COUNTY AGENCY 7. FEDERAL AGENCY <br />IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br />TY K HQ 44 Call 916 322-9669 if questions arise 421. <br />V- PETROLEUM UST FINANCIAL RESPONSIBILITY <br />I DICAM METHOD(s) ❑ 1. SELF-INSURffi1 ❑ 4. SURETY BOND is 7. STATEFUND ❑ 10. LOCAL OOVT MECHANISM <br />GUARANTEE❑ 5. LETTER OF CREDIT SNS. STATE FUND & CFO LETTER ❑ 99. OTHER: 432 <br />[3 3. ❑ 6. IDaMMON ❑ 9. STATE FUND & CD <br />VL LEGAL NOTIFICATION AND MAILING ADDRESS <br />Check one boxWmdi whichdime abouM be.md fa I%d mtifi .andmrl.. <br />I<enl mti5eatim and medmp will be a w dw tank owe.nWm b=1 or 3 s checked ®1. FACIIM ❑ 2 PROPERTY OWNER ❑ 3. TANK OWNER 4m. <br />VIL APPLICANT SIGNATURE <br />Cabr- im Ic.tify thn the '-fm WP-I&dh-ln a hoead a anm W the bmtof my kn kdea. <br />SIGNATURE OF APPLICANT <br />DATE4x4 PHONE 421. <br />A" AQV�(�'S <br />OS 209 <br />N OP APPLICANT (priN) 4x6 <br />TITLE OF APPLJUA I 4x7. <br />R � <br />awr�Eri <br />STATE UST FACILITY NUMBER (As., ye..oety) 4= <br />1998 UPGRADE CERTIFICATE NUMBER (n8g®c eery) 4z9. <br />(Sm Data Elommt 1, above. <br />UPCF Hvvlkv4c-o (L99) - I!1 httP:/A w .lmidom,,j Rev. 0246MO <br />