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#NIFIED PROGRAM CONSOLIDATEDVM <br />03 <br />lQ't T <br />UNDERGROUND STORAGE TANKS - FAC�I, 3 <br />page per site) Page of <br />TYPE OF ACTION ❑ I. NEW SITE PERMIT O 3. RENEWAL PERMIT ❑ $ CHANGE OF INFORMATION ❑ TPERMANFNTLY CLOSED SITE <br />(Check one item only) fi(4. AMENDED PERMIT specify change local use only ❑ S. TANK VED <br />❑ 6.TF PORARY SITE CLOSURE 5 <br />I. FACILI'T'Y / SITE INFORMATION <br />BUSINESS NAME (S.ne. FAm1rY NAME or nen -Dung Bar. Aa) 3 FACILITY IDN <br />� <br />q 1 <br />O (L k �%(S,rr2-a L F- ,) V^Fry ,.. �;' - 3 <br />NEAREST CROSS STREET $ao3 F iL ...a afo 401 ILI7Y OWNER TYPE ❑4.LOCALAGENCYIDISTRICT- <br />L p r L 1_ Rb ta�Kfon 1� L CORPORATION ❑ 5. COUNTY AGENCY* <br />BUSINGAS STATION ❑ 3. FARM Lj 5. COMMERCIAL ❑ 2. INDIVIDUAL ❑ 6. STATE AGENCY* <br />ESS 1. <br />TYPE ❑ 2. DISTRIBUTOR ❑ 4. PROCESSOR ❑ 6. OTHER 4o3 10 3. PARTNERSHIP ❑ 7. FEDERAL AGENCY* 402 <br />TOTAL NUMBER OF TANKS <br />Is facility can Indian Reservation or <br />e of supervisor of division, section or office which <br />•If owner of UST is a public agency: supervisor <br />REMAINING AT SITE <br />trusdands7 <br />operates the UST (This is the contact person for the tank records.) <br />3 4a <br />❑ Yes ❑ No 4os <br />406 <br />H. PROPERTY OWNER INFORMATION <br />PROPERTY OWNER NAME 407 <br />PHONE 40a <br />PKa,L, gCIL-,Dt�ES 1-tT--i'L0LF,LlVtA .e C- <br />MAILING OR STREET ADDRESS 400 <br />.O o / <br />CITY 410 <br />STATE 411 <br />ZIP CODE 42 <br />L 9`b <br />C A <br />9sZ �( i <br />PROPERTY OWNER TYPE 1. CORPORATION 2. INDIVIDUAL ❑ 4. LOCAL AGENCY DISTRICT Lj 6. STATE AGENCY <br />❑ 3. PARTNERSHIP ❑ 5. COUNTY AGENCY ❑ 7. FEDERAL AGENCY 413 <br />III. TANK OWNER INFORMATION <br />TANK OWNER NAME 4u <br />PHONE as <br />S A,Vv,� <br />MAILING OR STREET ADDRESS 416 <br />412 1 <br />STATE 418 <br />1 ZIP CODE 419 <br />TANK OWNER TYPE 1. CORPORATION 0 2. INDIVIDUAL 0 4. LOCAL AGENCY DISTRICT 0 6. STATE AGENCY 429 <br />❑ 3. PARTNERSHIP 0 5. COUNTY AGENCY Q 7. FEDERAL AGENCY <br />IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br />TY (TK) HQ 4¢ 1 1 1 1 1 1 Call (916) 322-9669 if questions arise 421 <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br />INDICATE MEMOD(s) ❑ I. SELF-INSURED ❑ 4. SURETY BOND ❑ 7.TATE FUND ❑ 10. LOCAL GOVT MECHANISM <br />❑ 2. GUARANTEE ❑ 5. LETTER OF CREDIT STATE FUND & CFO LETTER ❑ 99. OTHER ..... <br />❑ 3. INSURANCE ❑ 6. EXEMPTION ❑ 9. STATE FUND & CD 422 <br />VI. LEGAL NOTIFICATION AND MAILING ADDRESS <br />(beck one box to indicate which address should be used for legal noo catioru And m.lmg. <br />Legal notifications and mailings v 11 be sent to the tank owner unless box 1 or 2 is checked. ❑ 1. FACILITY 2. PROPERTY OWNER ❑ 3. TANK OWNER 4n <br />VII. APPLICANT SIGNATURE <br />Certification -1 certify that the Infonnit mvided herein is true and accurate b the best of my knowledge. <br />SIGNATURE 1 N <br />DATE I 424 <br />PHONE 425 <br />422 <br />NAME OF APPLICANT (print) 426 <br />TITLE OF APPLICANT <br />til 1 c (L 130 lG L 'D <br />STATE UST FACILITY NUMBER (For local., o*) 4m <br />1998 UPGRADE CERTIFICATE NUMBER (For Low ice only) 429 <br />UPCF (1/99 revised) 8 Formerly SWRCB Form A <br />