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U =..ED PROGRAM CONSOLIDATED F( 7DS <br />TANKS %iVr1 `laa�l�l� <br />UNDERGROUND STORAGE TANKS - FAC <br />- page per site) Page _ of <br />J(One <br />TYPE OF ACTION /OQ 1. NEW PERMIT [13. RENEWAL PERMIT [3S. CHANGE OF INFORMATION ❑ 7. PERMANENTLY CLOSED SITE a� <br />(Check one item only) 1/ ❑ 4. AMENDED PERMIT (Specify change) ❑ S. TANK REMOVED <br />❑ 6. TEMPORARY SITE CLOSURE <br />t MEr (P 05 R 0 I. FACIIdTY/SITE INFORMATION <br />B (S.es as FACILITY NAMB«DBA-Doing Busio. As) 3. <br />FACILITY <br />» <br />A <br />�° �I <br />,�c_ <br />o <br />a <br />s <br />NEAREST CROSS STREE wt. <br />FACILITY OWNER TYPE 4. LOCAL AGEN YIDISTRICT• <br />CORPORATION El5. COUNTY AGENCY• <br />❑ 2. INDIVIDUAL ❑ 6. STATE AGENCY• <br />14�. <br />BUSINESS I. GAS STATI 3. FARM COMMERCIAL ¢D_ <br />TYPE El2. DISTRIBUTOR El4. PROCESSOR ❑6. OTHER <br />❑ 3. PARTNERSHIP El7. FEDERALAGENCY• <br />TOTAL NUMBER OF TAN . <br />aoaor <br />Is facility on Indian Reservation.os. <br />•If owner of UST is a public agency: name of supervisor of divisionsection ar <br />REMAINING AT SITE ' (I <br />trust lands'3 <br />once which opent the UST. (This is the contact person for the tank words,) <br />62 2Z <br />Cl YC' <br />II. PROPERTY OWNER INFORMATION <br />PROPERTY OWNER NAME w7. <br />SAS �, l 7n Com, <br />PHONE ,og. <br />. <br />� 2 p <br />MAILING OR DDRESS 409, <br />Q� <br />CITY alo. <br />DG C � <br />STATE att. <br />G �' • <br />ZIP COQ3�Z/� nz. <br />U/7s <br />PROPERTY OWNER TYPE .CORPORATION 02.rNDrVIDUAL U 4. LOCALAGENCY/DISTRICT 06.STATEAGENCY 4t3. <br />❑ 3. PARTNERSHIP ❑ 5. COUNTY AGENCY ❑ 7. FEDERAL AGENCY <br />M. TANK OWNER INFORMATION <br />TANKOWNER NAME .ta. <br />rd,7,7e /^��_ <br />PHONE „s <br />��z o0 3 <br />MAILING OR STREE KESS ,16 <br />30 <br />O <br />CITY7 n7. 1 STATE als. ZIP CODE 419_ <br />S d� Dn/ 6�.7 S` / 3 - 0 o/D <br />TANK OWNER TYPE 1. CORPORATION 0 2. INDIVIDUAL U 4. LOCAL AGENCY/DISTRICT Lj 6. STATE AGENCY <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 1 Call 916 322-9669 if Bestions arise n. <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br />INDICATEMETHOD(s) ❑1. SELF-INSURED ❑a. SURETY BOND ❑7. STATE FIND ❑ 10. LOCAL GOVT MECHANISM <br />422 <br />❑ 2. GUARANTEE ❑ s. LETTER OF CREDIT [IS. STATE FUND & CFO LETTER ❑ 99. OTHER: <br />,2'y.INSURANCE ❑ 6. EXEMPTION ❑ 9. STATE FUND & CD <br />VI. LEGAL NOTIFICATION AND MAILING ADDRESS <br />Check one bot b itdeate which addrtaa should be used for legal ratifications aad -1 g. I <br />,,,...,,,/// <br />Legal notifications and mailings will be sent so the sank owner unless boa 1 ort u cbecke& ❑ L FACILITY ,gSI 2. PROPERTY OWNER ❑ 3. TANK OWNER 423 <br />VII. APPLICANT SIGNATURE <br />Certification: 1 unify, that the information provided herein is true and accurate m the best ofmy knowledge. <br />SIGNATUREOF"' ANT <br />/ <br />DATE �2� <br />PHONE ala. <br />�z-oo5 3 <br />NAME OF APPLICANT (print) 426 <br />TITLE OF AFTLICZANT a23. <br />STATE UST FACILITY NUMBER( .e.ty ata <br />1998 UPGRADE CERTIFICATE NUMBER(Aseney veeo I,) 429 <br />(Sec Data Element I, above.<- <br />UPCF Hwfwrea(1/99).1/2 http9/w .unidocs.org Rev. 02/16/00 <br />