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IED PROGRAM CONSOLIDATED FW <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> GIM amy <br /> Pays a <br /> TYPE OF ACTION 1 NEWSITE PERMIT 0 3.RENEWAL PERMIT 0 5 CHANGE OF INFORMATION(Spew7Y Marge- 0 77 PERMANENTLY CLOSED SITE <br /> (CAaek oho item onHlI w uao 0-1 TANK REMOVED 400 <br /> ❑ A.AMENDED PERMIT onw <br /> I.FACILITY I SITE INFORMATION qp all/ <br /> BUSINESS NAME(Same u FACILITY NAME w DBA-Do"Bwinssa AS) 3 FACILITY ID N - 1 <br /> NEAREST CROSS#rREET bt FACILITY OWNER TYPE <br /> �7'�'/w1/^� {] ,Y,/,� I /y ,1��Y ` 1 ❑ 1. CORPORATION 4. LOCALAGENCYA715fRILT <br /> W// rN U`^U✓ I�� Y'`�I N 0 2. INDIVIDUAL 0 5, CWNTY AGENCY' <br /> TVA ESS 0 1.GAS STATION 0 3.FARM 13 55.COMMERCIAL ❑ 3. PARTNERSHIP C3 6. SPATE AGENCY' <br /> 0 2.OISTRIBl7TOR 0 4.PROCESSOR 016 OTHER M3 0 T. FEDERAL AGENCY• 40Z <br /> TOTAL NUMBER OF TANKS Y fac,19,m IrMten Reaarv11hon d •If oNnv a UST a Pudic agency.roma a.0im ieon a <br /> REMAINING AT SITE b esidem ei diute.section w affk v4iiPP oPenalea Use UST. " <br /> N 404 ❑Y. HNP 405 (ihtete6»oor�cl-paean rw Ne honk ncwda)2PA 57V--) �e 0� � <br /> 1!5 <br /> I.PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME e'i: jel&-) 407 (PHDT'IE` ��'i- 2/O� 40B <br /> MAILING ON STREETADORE �'`J',vcQl/\ L 409 <br /> Z w <br /> CITY n 410 SI 411ZIP <br /> CODE 412 <br /> 5,3, <br /> PROPERTY OWNER TYPE 0 2. INDIVIDUAL E 4. LOCAL AGENCY I DISTRICT ❑ 6. STATE AGENCY 413 <br /> 0 1. CORPORATION 0 3. PARTNERSHIP 0 5. COUNTY AGENCY 0 7. FEDERAL AGENCY <br /> 1111-TANK OWNER INFORMATION <br /> TANK OMERyy��ME n 41 E 415 <br /> (=, l d� fu� 1p i 594-2ro8 <br /> MAILING OR STREET ADDRESS 416 <br /> Z n1. GJluvl <br /> CRY 417A 418 21P ODE 419 <br /> 2!pBrj � 3 <br /> TANK OWNER TYPE 0 2. INDIVIDUAL 4. LOCAL AGENCY I DISTRICT 0 6. STATE AGENCY 420 <br /> 0 1 CORPORATION 0 3. PARTNERSHIP 0 5. COUNTYAGENCY 0 7. FEDERALAGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HO 4 1 4 - Call(916)372-9 6W If quest=arise 421 <br /> V. PETROLEUM UST FINANCIZ RESPONSIBILITY <br /> INDICATE METHOD(S) 0 1. SELF-INSURED 0 4. SURETY BOND 7. STATE FUND 0 10 LOCAL GOVT MECHANISM <br /> 0 2. GUARANTEE 0 5. LETTER OF CREDIT ❑ 6. STATE FUND d CFO LETTER ❑ W. OTHER: <br /> 0 3. INSURANCE 0 6. EXEMPTION 0 9. STATE FUND 8 CO 422 <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one box to indicate nT¢h edd.iiinM M ue11d far 1.9111 notitiolMona nw mailing. El 1. FACILITY 2. PROPERTY OWNER 0 3. TANK OWNER 423 <br /> L.9al notAKsbons and mail).9e will Iie sant te Tho tank o•aler unless koa 1 w 2 is chocked. <br /> VIL APPLICANT SIGNATURE <br /> Cemlka' )Ic y Nat",Nw/yurtion Provided n e110 axwde W dne hest of my kno sege <br /> SIGNA R PALIC - DATE 424 PHONE� 425 <br /> NAME OKAPPYCANT(Nmy <br /> A. /, 426 TITLE OF APPLICANT 427 <br /> BVI <br /> STV I, ��171� <br /> UPCF(1 1) /'R - 5358 FGTTafIy SWRCB Fam a <br /> Tt 5/5-350 <br />