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. UN?• ') PROGRAM CONSOLIDATED FORD"_-� <br />6/3/03 <br />�W �� TANKS <br />UNDERGROUND STORAGE TANKS - FAC11,11-Y <br />(one page Per site) Page _Lof A_ <br />IN Pf; Or ACT ION ❑ 1 NEWSITF. PERMIT O 1. RENEWAL PERMIT s.CfUNOE OF INFORMATION O 7PFFtMANFNTLYCI.OSEOSIIF <br />N hrk mN nem nnlyl ❑4 AMENDED PERMIT specify elange Incalmeonly O 8 TANK REMOVED <br />❑ &TEMPORARY SITE CLOSURE <br />L FACILITY/ SITE INFORMATION <br />I$(rl:CS SNA(MlE IS- a fAe'ILITY NAME w nnA .Roma ammnr Ap 1 FACILITY IQp <br />NFAREST CROSS ST -RE T I A Lj _I <br />q4�/lr�U` <br />' <br />FACILITY OWNER TYPE 4. LOCAL GENCY/DISTRICT• <br />S� r� 1 <br />CORPORATION [I5. COUNTY AGENCY* <br />E]2. INDIVIDUAL El 6, STATE AGENCY •• <br />.BUSINr3SS S STATION 3. F RM 5. COMMERCIAL <br />P;, <br />I YPE ❑ 2. DISTRIBUTOR ❑ 4. PROCESSOR 0 6. OTHER 401 <br />❑ 3. PARTNERSHIP ❑ 7. FEDERAL AGENCY- 4V7 <br />10T AI NI IMBER OF TANKS <br />Is facility on Indian Reservation or <br />•Ifowueror USTisapoblicssency�nsn<ofsyrervisor of division. section or office whiTh <br />REMAINING AT SITE <br />Itusllands? <br />operates the UST (This is the contact permd Ric the tank records.) <br />4w <br />Cl Yes No 405 <br />ms <br />11. PROPERTY OWNER INFORMATION <br />PI!OPIiR Y OWNER NAME 401 PHONE ms <br />-I <br />M IN(i ORSTRF.ETADI RESS- oN <br />4 Zc:, <br />Uy 410 <br />s I <br />STATE 411 <br />ZIP CODE a: <br />PR()1•r'R I Y OWNER TYPE Qql.CC1RPORArION 02ANDIVIDUAL Lj 4. LOCAL AGENCY / DISTRICT C STATE AGENCY <br />❑ 3. PARTNERSI IIP ❑ 5. COUNTY AGENCY ❑ 7. FEDERAL AGENCY 4I! <br />III. TANK OWNER INFORMATION <br />IAUK OWNFR NAME 414 PI ZONE n] <br />r <br />t3 � r _ o - <br />41" . <br />ArJI <br />rd 1`RIri OR REP:r nD ) ESS <br />Q <br />r Y 417 <br />STATE us <br />ZIPCODE nv <br />S -G-) vxL(r0.1 <br />- <br />g cS�i 13^O <br />I ANP. OWNER TYPE LCORPORATION 02ANDIVIDUAL U 4. LOCAL AGENCY/DISTRICT U6STATEAGENCY and <br />❑ 3 PARTNERSHIP ❑ S. COUNTY AGENCY ❑ 7. FEDERAL AGENCY <br />IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br />I Y (TK) HQ 44- Call (916) 322-9669 if questions arise 471 <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br />INDICATE MF.TIIOD(s) ❑ 1. SELF-INSURED ❑ 4. SURETY BOND [17. STATE FUND ❑ 10. LOCAL GOVT MECHANISM <br />❑ 2. GUARANTEE ❑ 5. LETTER OF CREDIT ❑ 9. STATE FUND Bc CFO LETTER ❑ ".OTHER: <br />❑ 3. INSURANCE ❑ 6. EXEMPTION ❑ 9. STATE FUND do CD 477 <br />VI. LEGAL NOTIFICATION AND MAILING ADDRESS <br />-r heck ow. box In indicate which address slauW be used fol legal notifications and nailing. <br />1 eget mnifaaliom and tmilings will be sent to the lank owner unless box 1 072 is checked. ❑ I. FACILITY 92. PROPERTY OWNER ❑ ). TANK OWNER 421 <br />V11. APPLICANT SIGNATURE <br />r'enipcainn - I « niry that The information provided herein is hue and accun a to the best of my knowledge. <br />Sf(;NA TURF. PL ' NT <br />DATE 4}4 <br />PHONE 411 <br />piin414 <br />rdAMr: 1" LIg <br />TITLE OF APPLICANT 477 <br />/ <br />// r .`J - r <br />v <br />S I A I P. UST FACfI.fI Y NUMBER Iron kcstvre..ntyl 418 <br />1999 UPGRADE CERTIFICATE NUMBER IF., ked Ore only) <br />4is <br />IJPCF (1/99 revised) <br />171 <br />\a/ �"d <br />Folnlcrly SWR( H Poen ,1 <br />