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9 kt7r�gaol <br /> ED PROGRAM CONSOLIDATED FO }(t Q!G <br /> TANKS / <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> • (One page per site) Page_of <br /> TYPE OF ACTION 1.NEW PERMIT ❑3.RENEWAL PERMIT ❑5.CHANGE OF INFORMATION ❑7.PERMANENTLY CLOSED SITE 400. <br /> (Check one item only) ❑4.AMENDED PERMIT (Specify change) ❑8.TANK REMOVED <br /> ❑6.TEMPORARY SITE CLOSURE <br /> L FACILITY/SITEINFORMATION <br /> BUSINESS NAME ISame as FACILITY NAME or DBA-Doing Business As) 3. FACILITY / <br /> 106397 Dn Ji <br /> NEAREST CROSS STREET 401. FACILITY OWNER TYPE ❑4.LOCAL AGENCY/DISTRICT* 402, <br /> p o�-na C-w c ow 711.CORPORATION ❑5.COUNTY AGENCY* <br /> BUSINESS 1.GAS STATION [13.FARM ❑5.COMMERCIAL 403. ❑2.INDIVIDUAL El 6.STATE AGENCY* <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR 6.OTHERS y�,,, ❑3.PARTNERSHIP ❑7.FEDERAL AGENCY* <br /> TOTAL NUMBER OF TANKS 404. Is facility on Indian Reservation 405. *If owner of UST is a public agency:name of supervisor of division,section or 4W <br /> REMAINING AT SITE or trust lands? office which operates the USE. (This is the contact person for the tank records.) <br /> f (75 '733 <br /> []Yes P No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 408. <br /> Ct-r-v of- 27c c.Ic ,,j <br /> MAILING OR STREET ADDRESS 469. <br /> 30S- <br /> CITY <br /> oSCITY 4m. STATE 411, ZIP CODE 412. <br /> CSi- c) 12 0 2 <br /> PROPERTY OWNER TYPE ❑ 1.CORPORATION ❑2.INDIVIDUAL �Fj 4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 413. <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> III.TANK OWNER INFORMATION <br /> TANKOWNERNAME 414. PHONE 415. <br /> U r.J�c aawt•J <br /> MAILING OR STREET ADDRESS 416. <br /> CITY 417. STATE 418, ZIP CODE 419. <br /> TANK OWNER TYPE ❑ 1.CORPORATION [12.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 426. <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY [17.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 1 1 1 1 1 1 Call(916)322-9669 if questions arise 421. <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ❑ I.SELF-INSURED ❑4.SURETY BOND ❑7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM 422 <br /> ❑2.GUARANTEE ❑5.LETTER OF CREDIT ❑8.STATE FIIND&CFO LETTER 99,OTHER:Ua pJ,...;.J <br /> ❑3.INSURANCE ❑6.EXEMPTION ❑9.STATE FUND&CD <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check Beobox to indicate which address should be used for legal notifications and mailing. 611,_ .N jl C eL <br /> Legal notifications and mailings will be sent to the tank owner unless box I or 2 is checked. ❑ 1.FACILITY [12. PROPERTY OWNER ❑ 3.TANK OWNER 421 <br /> VII.APPLICANT SIGNATURE <br /> Certification: I certify that the information provided herein is we and accurate to the best of my knowledge. <br /> SIGNATURE OF APPLICANT DATE 424, PHONE 425. <br /> y/3o) oH Caoa)g3y_ 9oY� <br /> NAME OF APPLICANT(print) 426. TITLE OF APPLICANT 427. <br /> ..rs Y_ P4.4_O� P�sru c - <br /> STATE EST FACILITY NUMBER(Agency use only) - 428. 1998 UPGRADE CERTIFICATE NUMBER(Agency use only) 429, <br /> (See Data Element 1,above. <br /> UPCF Hwfwre-a(1/99)-1/2 http://Nv%w.unidocs.org Rev.02/16/00 <br />