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I, .D PROGRAM CONSOi.IDATF.D FORM d�_tTANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY �a // � <br /> u <br /> (Doe Pegs Per site Page_of_ <br /> TYPE OF ACTION 1.NEW SITE PERMIT [13.RENEWAL PERMIT ❑S.CHANGE OF INFORMATION ❑ 7PERMANEMIY CLOSED SITE <br /> (Cock Doe i�odY) ❑4.AMENDED PERMIT meoify dog, local um ooly ❑ 8.TANK REMOVED <br /> ❑6.TEMPORARY SITE CLOSURE <br /> L FACILM/SITE INFORMATION <br /> BU S NAME -FACULTY NAME V DBA-Dome a Ae) 3 FACILITY11M <br /> NEAREn.CRO STREET LOQ 7Y/ar�rt -`f 4DI FACHITY OWNER TYPE 4.LOCAL AGENCY/DISTRICI` <br /> 95a o 2 [] 1.CORPORATION D 5.COUNTY AGENCY* <br /> BU_SRMi.GASsTATION LJ3.FARM 5.-COMMERCIAL D 2.INDIVIDUAL ❑6.STATE AGENCY' <br /> TYPE Z12 DISTRIBUTOR El 4.PROCESSOR❑6. OTHER Oto PARTNERSHIP - [] 7.FEDERAL AGENCY- 4m <br /> TOTAL NUMBER OF TANKS is facility on Indim Renovation or -If o of UST u.public ageoey:Dame of supervum of Mom,aemioD m office whist <br /> REMAINING AT SITE aunUmcis7 W. the USTCrbeotheeooun Pa fmthennkamds) <br /> / ❑ Y. . <br /> 425 aan <br /> II. PROPERTY OWNER INFORMATION <br /> PROP TY OWNER NAME 'ol PHONE act <br /> /,j Sl <br /> MAILING OR STREET ADDRESS <br /> ,+ CITY <br /> oto ST C att ZIP CODE // au <br /> I Off/ <br /> LU <br /> PROPERTY OWNERTYPE 1.CORPORATION 2.INDIVIDUAL 4.LOCAL AGENCY/DISTRICT 6.SPATE AGENCY <br /> � .PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY 413 <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 4M PHONE 4D <br /> / ��J z 3 /S <br /> MAILING OR STREET ADDRESS a1s <br /> IN <br /> r� STilf Sv� � aoo <br /> CrrY An STATE Ott ZIP COD 419 _ <br /> Y F� <br /> TANK OWNER TYPE I.CORPORATION IINDIVIDUAL 4.LOCALAGENCY/DISI'R.1CT &STATEAGENCY 40 <br /> PARTNERSHIP 0 S.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> TV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY HQ 44 <br /> Call 916 322-9669 if questions arise 4tl <br /> V PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> - INDICATE METHOD($) ❑ 1.SELF-INSURED ❑4.SURETY BOND ❑7.STATE FUND D 10.LOCAL GOVT MECHANISM <br /> E]2.GUARANTEE ❑5.LEITER OF CREDIT ❑8.STATE FUND&CFO LETTER D 99.OTHER. <br /> .INSURANCE [16.EXEMPTION D 9.STATE FUND&CD m <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> - Cheek arc box m Lod_ ,J"b AArt shnmtl be used for legal vofifiotioas and znwimg. <br /> IDI mdfimiom and®iIWPg ill be amt m me sank oo r u-IM box 1.2 i.rJxskrd. ❑ 1.FACULTY ❑2 PROPERTY OWNER 0 3.TANK OWNER Am <br /> VII.APPLICANT SIGNATURE <br /> Cadfieadm-1 the information provided hmein uwe mode u,to the best of my knowledge. <br /> SIGNATU F PL DATE AN PHONE an <br /> G � v <br /> NAME-OF-APPLICANT(pont) G/ <br /> am OF I <br /> ATE UST FACILITY NUMBER i F«tool,...won <br /> 4zt 11998 UPGRADE CERTIFICATE NUMBER(Fwl mw my) 4N <br /> UPCF(1/99 revised) 8 Formerly SWRCB Form A <br />