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IED PROGRAM CONSOLIDATED FO 2 <br /> TANKSJ\ <br /> UNDERGROUND STORAGE TANKS - FA LIT (one PaBp S\\ �� I <br /> G sit age of 1 <br /> TYPE OF ACTION ❑1.NEW PERMIT 113.RENEWAL PERMIT [15.CHANGE OF INFORMATION :/ [37.PERMANENTLY CLOSED SITE 400 <br /> (Check one item only) ❑4.AMENDED PERMIT (Specify change) ®3.TANK REMOVED <br /> [16.TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION <br /> BUSINESS NAME(sa,ne as FA(:ILITV NAME or onA-nomg nuslness As) s, FACILITnY .;"_"' <br /> BENNY PROPERTY IDa r�/ $ ' <br /> NEAREST CROSS STREET �a� 401. FACILITY OWNER TYPE ❑4.LOCAL AGENCY/DISTRICT" 402. <br /> NORTH STREET ❑ 1.coAPOAAT1oN ❑5.COUNTY AGENCY' <br /> BUSINESS ❑ I.GAS STATION ❑3.FARM ❑5.COMMERCIAL 403 ®2.INDIVIDUAL ❑6.STATE AGENCY* <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR M 6.OTHEA ❑3:PARTNERSHIP ❑7.FEDERAL AGENCY' <br /> TOTAL NUMBER OF TANKS 4a. Is facility on Indian Reservation 4os. •If owner of UST E a public agency: name of supervisor of division,section or 4M6 <br /> REMAINING AT SITE or trust lands? office which operates the T. (This is the contact person for the tank records.) <br /> ONE ElY. M No <br /> IL PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408, <br /> VICTOR BENNY 916-645-5507 <br /> MAILING OR STREET ADDRESS 409 <br /> 1154 SECRET LAKE LOOP <br /> CITY 419. 1 STATE 411. ZIP CODE 411 <br /> LINCOLN CA 95648 <br /> PROPERTY OWNER TYPE ❑ I.CORPORATION M 2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT 06.S AGENCY 413. <br /> ❑3.PARTNERSHIP [715.COUNTY AGENCY [:17.FEDERAL AGENCY <br /> III. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415. <br /> SAME AS ABOVE <br /> MAILING OR STREET ADDRESS 416. <br /> CITY 417, 1 STATE 413, ZIP CODE 419, <br /> TANK OWNER TYPE ❑ I.CORPORATION El 2.INDIVIDUAL El 4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY azo. <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> 1'Y TK ]IQ 44- Call 916 322-9669 if questions arise 421 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ®1.SELF-INSURED ❑4.SURETY BOND [17.STATE FUND ❑ 10.LOCAL GOVT MECHANISM 422 <br /> [12.GUARANTEE ❑5.LETTER OF CREDIT [18.STATE FUND&CFO LETTER ❑99.OTHER: <br /> [13.INSURANCE ❑6.EXEMPTION ❑9.STATE FUND&CD <br /> VI. LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one box to indicate which address should be used for legal notifications and mailing. <br /> Legal notifications and mailings will be sent to the tank owner unless box 1 or 2 is checked. ❑ ].FACILITY E2. PROPERTY O WNER ❑3.TANK OWNER 423- <br /> VII. APPLICANT SIGNATURE <br /> Cenific Lan: 1 rt that the inf ntrition provided herein is true and accumic to the best of my knowledge. <br /> SI FA CA DATE 424, <br /> PHONE 425 <br /> 04-23-2004 209-467-1006 <br /> APPLICANT(print) 426. TITLE OF APPLICANT 427. <br /> CHRISTOPHER MILLER AGENT FOR OWNER(Advanced GeoEnvironmental) <br /> STATE UST FACILITY NUMBER(Agency use only) 423. 1998 UPGRADE CERTIFICATE NUMBER(Agency use only) 419. <br /> (See Data Element 1,above. <br /> UPCF Hwfwre-a(1/99)-1/2 http://www.unidoes.org Rev.02/16/00 <br />