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4 ED PROGRAM CONSOLIOATEO FO <br /> Tas 6/y 'I I0� <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> one^ace o6rada <br /> Pegs _ of <br /> TYPEOFACTION Q 1.NEW SITE PERMIT 03.RENEWAL PERMIT 5.CHANGE OF INFORMATIONSpeo/y Mange- ❑ 7.PERMANENTLY CLOSED S O <br /> (C.1ecY....tem aMy/ <br /> ❑ a.AMENDED PERMIT 1o'a1°�°^11'1 ❑ 9.TANK REMOVED 1 'I <br /> 0 S.TEMPORARY SITE CLOSURE yol <br /> I.FACILITY/SITE INFORMATION <br /> BUSINESS NAME B..as FACIUTY NAME or DBA-Ooing Suemaaa Aa) 3 FAGUTYIDC _ ^' <br /> p by <br /> T ce�g� . �lL iwt licr- <br /> NEARESTCROSSS(T`REE1T.^_� - dpt FACIUTYOWNERTYPE �p7, LAG�Cy�ISTRILT <br /> 33b e� l�J�.t'� C CORPORATION AA <br /> ❑ 2 INDIVIDUAL 0 S. CC11NT/AGENCr <br /> BUSINESS 1 GAS STATION 0 3.FARM 0 S.COMMERCIAL 0 S. STATE A GENS <br /> TYPE ❑ 1 PARTNERSHIP 0 T. FEDERAL AGENCY' 402 <br /> ❑ 2.DISTRIBUTOR ❑ d.PROCESSOR 6.OTHER 403 <br /> TOTAL NUMBER OF TANKS Ia faetip on lm.Ria.vonor '?f.er of USTapubIn., nq:nemeefwb w <br /> REI,MWINGATSITE z� vua6anas? bmsion,"Mon°rolfim m=opanamme UST. <br /> 404 (Thu is me mons paaen ma m 1 4yy <br /> ❑Yea NO Ops `+.6' �� r`ir y c% iw i C+'R <br /> Il.PROPERTY OWNER INFORMATION <br /> PROP RTY .. a' 40] PHONE 406 <br /> a fir( °C <br /> MAILING OR SIRE ADORES aN y4pg <br /> CITY P 410 STATE, 4n JP CODE y� 41 <br /> PROPERTY OWNER TYPE 0 2, INDIVIDUAL Z*.. LOCALAGENCYICISTRICT 0 6. STATEAGENCY 413 <br /> ❑ 1. CORPORATION 0 ] PARTNERSHIP ❑ 5. COUNTYAGENCY ❑ ]. FEDERALAGENCY <br /> III.TANK OWNER INFORMATION <br /> TANK,OWNIERNAME >^.. 414 PHONE � 415 <br /> MAIUNG OR STREET ADDRESS 416 <br /> _ <br /> uly <br /> 1 i� 41] STATE 415 Z:PCOCE` a19 <br /> TANK OWNER TYPE 0 2. INDIVIDUAL LOCALAGENCY/DISTRICT 0 6. STATEAGENCY 420 <br /> ❑ 1. CORPORATION 0 ] PARTNERSHIP 0 5.COUNTYAGENCY C ]. FEDERALAGEN(.Y <br /> N.BOARD OF EQUALIZATION UST STORAGE-FEE ACCOUNT NUMBER <br /> TY(TK)HO a a - Call(916)322-9669 if questions ansa 421 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOO(S) 0 1. SELFANSURED 0 4. SURETY BOND 0 7. STATE FUND 0. LCCALGOV7MECWWISM <br /> 0 2 GUARANTEE 0 5. LETTER OF CREOR 0 & STATE FUND&CFO LETTER 0 99. OTHER: <br /> 0 3. INSURANCE 0 6. EXEMPTION 0 9. STATE FUND&CD 422 <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS' <br /> Clterk am Ooa m intioa wlYtl1 atlNem aflOitlC be assn mr uga na9fiogana am mailing, ❑ t. FACILITY 2 PROPERTY OWNER ❑ 3.TANK OWNER 423 <br /> Legal nbe6®eons tum malbtgs w 11 be aef6 m m rink vaw nmaa nm t a2 is Masi <br /> — V9.APPLICANT SIGNATURE <br /> C. <br /> 010MUM, I°erM'/9Mrms a°abss flermll u hla amamtfam m as Oea of my kfpwMggs. <br /> NRE AP P DATE 424 PHONE 425 <br /> wAy�,:s,,COAP <br /> �FPUy'ANT(pnrtr) 426 TITLE "1PUCma d 427 <br /> 7... C'1 <br /> STATE USTFACILITYNUMBER(Fm/aolu»aay/ 428 1996UPGRADECERnFIATENUMBER(F-Po saeamw 429 <br /> UPCF(1199) FDenerly SYN3CB Form A <br />