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UN "'IED PROGRAM CONSOLIDATED F " FM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> __=I-Leper sde) <br /> Pao. _ a <br /> TYPE OF ACTION 1 NEW SITE PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION <br /> (Cnecx orre It"',omy) �,...� (specify as/ye- ] PERMANENTLY CLOSED SITE <br /> X.. MENDED PERMIT JOW-m 0*) ❑ B.TANK REMOVED x00 <br /> . ❑ 6.TEMPORARY SITE CLOSURE <br /> Mi jAkr "jwim I.FACILITY/SITE INFORMATION <br /> BUSINESS NAME(SrtM w FACBITY NAME or DBA•Doig ll M At) 3 FACILITY ID♦ t <br /> y <br /> NEAREST CROSS STREET 401 FACILITY OWNER TYPE ❑4 LOCAL AGENCYOSTRICr <br /> C 'K1. CORPORATION ❑ S COUNTYAGENCY' <br /> J ❑ 2. WOMOUAL <br /> BUSINESS 1.GAS STATION ❑ 3.FARM ❑ 5.COMMERCIAL ❑ 6. STATE AGENCY• <br /> TYPE ❑ 3. PARTNERSHIP <br /> ❑ 2.DISTRIBUTOR ❑ 4.PROCESSOR ❑ 6.OTHER 403 ❑ 7 FEDERAL AGENCY• 402 <br /> TOTAL NUMBER OF TANKS Is fiI on Yrdan Re4erYrm or I ' vi nar a UST a•puptio age roma a supuvaa of <br /> REMAINING AT SITE tn,,Mwlde7I dN oton.a acWn a ol/re~aoerrtaa tM UST. <br /> 4W (TMG a etc oontw penin w eM I"remrm.) <br /> ❑Yat 405 1 �j A 408 - <br /> II.PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME40] � NE 403 <br /> N s I 15 7-79 -7:102 <br /> MAILING OR STTIEET ADDRESS <br /> U "' -710 '°' <br /> I 410 A 411 ZIP CODE 412 I <br /> ANmOcN I G "F 94-509 <br /> PROPERTY OYMER TYPE 1313Z INDIVIDUAL ❑1. LOCAL AGENCY/DISTRICT 6. STATEAGENCY 413 <br /> �1. CORPORATION ❑ 3. PARTNERSHIP ❑ 5. COUNTYAGENCY ❑ 7. FEDERALAGENCY <br /> 111.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 P E 415 I <br /> C I q 25 - 0 <br /> MAILING OR S ET ES <br /> 118 <br /> u 10 <br /> CITY AIV 1 1oc"H n CAVE,E, 1WATL 4111 IP `"I O_I 419 1 <br /> I <br /> TANK OWNER TYPE 1p�B/� ❑ 2. INOMDUAL 134. LOCAL AGENCY I DISTRICT ❑6. STATE AGENCY 420 <br /> ' CORPORATION ❑ 3. PARTNERSHIP ❑ 5. COUNTYAGENCY ❑ 7 FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 4 4 _ I <br /> � � l i i ; i Call(916)322.9669 if questions arise 421 i <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(S) 1. SELF4NSURE0 ❑ 4 SURETY BOND ❑ 7. STATE FUND ❑ 10 LOCALGOVTMECHANISM <br /> ❑ 2. GUARANTEE ❑ 5. LETTER OF CREDIT ❑B STATE FUND 6 CFO LETTER ❑ 99 OTHER. <br /> ❑ 3. INSURANCE ❑ 6. EXEMPTON ❑9. STATE FUND i CD 422 <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> 1 Cni A one dM to ndioit vNpr eeoress cupid M uew to,"a ncnir"i "m44ny. <br /> Legal na4rationa Gra muln9e wa G l4a b OM ta4 own4r uvese Ooa 1 w 2 a ❑ 1 FACILITY ❑ 2. PROPERTY OWNER 3. TANK OYNIER 123 <br /> VII.APP ANT SIGNATURE <br /> CeaAulan I t4Ny Wr dr W.2:2trn n is 501uw9411te to Va p.r a bwad9e <br /> SIGNATURE OF APPLICANT DATE 424 - P ONE 425 <br /> � � q1 92s 8 - 71D2- <br /> I <br /> NAME OF APPLICANT(pn ) 426 1 TITLE Off APPLCANT 427 <br /> r NSIM-DW MANAatm - &UILOf" <br /> Fwvlw/2(Sel LIC. <br /> STATE UST FACILITY NUMBER(For local rue ony) 426 1 1999 UPGRADE CERTIFICATE NUMBER I wWWM ony) 429 <br /> UPCF(1/99 revised) 6 <br /> Formerly SWFtCB Form A <br />