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• low IFIED PROGRAM CONSOLIDATED 0M <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> pRB B e sfB <br /> ►,( Page _ m <br /> _ <br /> TYPEOFACTION 01 NEW Ly SITE PERMIT 0 3.RENEWAL PERMIT S CHANGE OF INFORMATION(Speaty Matto- ❑ 7.PERMANENTLY CLOSED SITE <br /> (Cneal..'ter, my) C3 4.AMENDED PERMIT se local uPmy) 0 S.TANK REMOVED 400 <br /> ❑ e.TEMPORARY SITE CLOSURE <br /> I.FACILITY I SITE INFORMATION <br /> BUSINESS NAME(Same FACILITY1 NAM aro -Wilg1Buamu A. 3 FACILITY IDS 1 <br /> QkNw �nawt oX" . - Qacav <br /> NEARE TCROSSS REFr\ <br /> T C A 401 FACILITY OWNER TYPE P's. LOCAL AGENCYIDISTRICT' <br /> 5 -a%A S \a.uS V�F�e ❑ 1. CORPORATION 0 5. COUNTYAGENCr <br /> 0 2. INDIVIDUAL 0 B. STATEAGENCY- <br /> BUSINESS 0 i GAS STATION 0 3.FARM 0 5.COMMERCIAL 0 3. PARTNERSHIP ❑ 7. FEDERAL AGENCY' 402 <br /> TYPE <br /> ❑ 2.DISTRIBUTOR ❑ 4.PROCESSOR B.OTHER 403 <br /> TOTAL NUMBER OF TANKS is laaliry on Iwen Reservation or 'll ownx of UST a pu0sc a9elwy.name M wptrn of <br /> REMAINING AT SITE eu4tlanW7 1fm,m ofUSnor 0..wfiitll operates to UST. <br /> (This is me wn=parson for the tank ,some, <br /> 4W ❑Yes US No 405 � <br /> 11.PROPERTY OWNER INFORMATION <br /> P OPE TY OWN R NAME 407 PlgNE a0B <br /> e e�e�o vineln a cC v. 2D5.93-1• <br /> MAILING OR STREET RESS w9 <br /> 02 R cc <br /> Cm• 1{- 410 STATE iii ZIP COE 412 <br /> ^y <br /> d N CA <br /> \SZOZ <br /> PROPERTY OWNER TYPE ❑ 2. INDIVIDUAL X4. LOCAL AGENCY I DISTRICT 0 6. STATE AGENCY 413 <br /> ❑ 1. CORPORATION 0 3 PARTNERSHIP ❑ S. COUNTY AGENCY ❑ 7. FEDERALAGENCY <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> Mpkaso <br /> MAILING OR STREET ADDRESS 416 <br /> CITY 417 STATE 410 ZIPCOOE 419 <br /> TANK ONMER TYPE 0 2. INDIVIDUAL 4. LOCAL AGENCY I DISTRICT 06. STATE AGENCY 420 <br /> ❑ <br /> I. CORPORATION 0 ] PARTNERSHIP 0 S. COUNTY AGENCY C 7. FEDERALAGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HO 1 4 1 4J_j Call(916)322-9669 if questions arise 421 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHODFI <br /> S) 0 1. SELNSURED 0 4. SURETY BOND 0 7. STATE FUND 10. LOCAL GOVT MECHANISM <br /> 0 2 GUARANTEE 0 5. LETTER OF CREDIT 0 B. STATE FUND a CFO LETTER 0 99. OTHER: <br /> 0 3. INSURANCE 0 6. EXEMPnON 0 9. STATEFUNDSCO 42Z <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Cleat ore Dox to adcate w W aBlesss MIoMO 0e Yeas for WIN tmtifloasoes aw mating. ❑ 1. FACILITY 2. PROPER IYOWNER 0 3.TANK ONMER 423 <br /> Legal notifltstian..w malims wit to sent w me=K orwrwsau sox 1 ort is ormo 1111 <br /> -- VII.APPLICANT SIGNATURE <br /> rtSloasort Icaw Wasehater,is eve,sw aoaltax,to W best d my immewd9a. <br /> TUREOF DATE 4N PHONE 425 <br /> Owv�eL� a ew b 2O o f <br /> APw yf 428 nnE D rJwr 427 <br /> l h Nasty. , SSIg $ <br /> STATE UST FACILITY NUMBER(Fcrforsl use wti) 428 1998 UPGRADE <br /> EERMCATE NUMBER(Farb/JoCl�us oNy) 429 <br /> UPCF(1/99) - I J� ' JOI - I FOmlery SWRCBFonnA <br />