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IED PROGRAM CONSOLIDATED FO 04 <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FA vx k)-r)'p� <br /> (One page per sitage of I <br /> TYPE OF ACTION El1.NEW PERMIT ❑3.RENEWAL PERMIT ❑5.CHANGE OF INFORMATION ❑7.PERMANENTLY CLOSED SITE 400. <br /> (Check one item only) [14.AMENDED PERMIT (Specify change) ®8.TAMC REMOVED <br /> ❑6.TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION <br /> BUSINESS NAME(samc as FACIUTYNAMEo,DBA-Demg nusloc:,As) 3. FACILITY <br /> BENNY PROPERTY Da�� 5 I <br /> NEAREST CROSS STREET �a.� 401. FACILITY OWNER TYPE ❑4.LOCAL AGENCY/DISTRICT" 4°2. <br /> NORTH STREET El1.CORPORATION ❑ 5.COUNTY AGENCY' <br /> BUSINESS El 1.GAS STATION ❑3.FARM ❑5.COMMERCIAL 003' ZI 2.INDIVIDUAL ❑6.STATE AGENCY' <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR ®6.OTHER ❑3.PARTNERSHIP ❑7.FEDERAL AGENCY" <br /> TOTAL NUMBER OF TANKS 404 Is facility on Indian Reservation 405. *If owner of UST is a public agency:name of supervisor of division, section or 406. <br /> REMAINING AT SITE or trust lands? once which operates the UST. (This is the contact person for the tank records.) <br /> ONE ❑Yes ®No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME J07- PHONE 408. <br /> VICTOR BENNY 916-645-5507 <br /> MAILING OR STREET ADDRESS 009' <br /> 1154 SECRET LAKE LOOP <br /> CITY 410- STATE 41L ZIPCODE 412. <br /> LINCOLN CA 95648 <br /> PROPERTY OWNER TYPE ❑ 1.CORPORATION ®2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 413_ <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERA I.AGENCY <br /> III. TANK OWNER INFORMATION <br /> TANKOWNERNAME 414. PHONE 415. <br /> SAME AS ABOVE <br /> MAILING OR STREET ADDRESS 416, <br /> CITY 417. STATE 418. ZIP CODE 419. <br /> TANK OWNER TYPE ❑ 1.CORPORATION Lj 2.INDIVIDUAL Ej 4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 420. <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY TK HQ 44- T7 I I I Cal] 916 322-9669 if questions arise 421 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) Z L SELF-INSURED ❑4.SURETY BOND ❑7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM 421 <br /> ❑2.GUARANTEE ❑5.LETTER OF CREDIT [18.STATE FUND 3e CFO LF.'ITER ❑99.OTHER'. <br /> ❑3.INSURANCE ❑6.EXEMPTION ❑9.STATE FUND k 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 lank owner unless box I or 2 is checked. ❑ 1.FACILITY ® 2. PROPERTY OWNER ❑ 3.TANK OWNER 423, <br /> VII. APPLICANT SIGNATURE <br /> CeniOr flan: I ri that the information provided herein is true and accurate to the best of my knowledge. <br /> SI F A CA DATE 424' PHONE azs <br /> 04-23-2004 209-467-1006 <br /> A APPLICANT(print) 026 TITLE OF APPLICANT 427. <br /> CHRISTOPHER MILLER AGENT FOR OWNER(Advanced GecEnvironinental) <br /> STATE UST FACILITY NUMBER(Agency use only) 428' 1998 UPGRADE CERTIFICATE NUMBER(Agmey use only) 429 <br /> (See Data Element 1,above. <br /> UPCF Hwfwrc-a(1/99)-1/2 http://www.unidocs.org Rev.02/16/00 <br />