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iV <br /> U1.__ D PROGRAM CONSOLIDATED FO <br /> TANKS (�'y 13 le y <br /> UNDERGROUND STORAGE TANKS - FACIL oTYne ge per site) Page_of <br /> aoo. <br /> TYPE OF ACTION ❑1.NEW PERMIT C13.RENEWAL PERMIT ❑5.CHANGE OF INFORMATION ❑7.PERMANENTLY CLOSED SITE <br /> (Check one item only [14.AMENDED PERMIT (Specify change) <br /> ❑8.TANK REMOVED <br /> ❑6.TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION <br /> BUSINESSNAME(S=casFACILITYNAMEorDBA-DoingBusineiiPS 3, FACILITY I. <br /> 3j4 pAe C&.1ra&W ID# <br /> NEAREST CROSS STREET 401 FACILITY OWNER TYPE ❑4.LOCAL AGENCY/DIS I KIC 1 402. <br /> Sr.Q N/sL4a f ® 1.CORPORATION ❑5.COUNTY AGENCY* <br /> ❑6.STATE AGENCY* <br /> BUSINESS Ml.GAS STATION ❑3.FARM [15.COMMERCIAL 403 ❑2.INDIVIDUAL PARTNERSHIP ❑7FEDERAL AGENCY* <br /> TYPE ❑2.DISTRIBUTOR F14.PROCESSOR ❑ 3.PARTNE .6.OTHER ❑ 406. <br /> Indian Reservation 4D5 *If owner of UST is a public agency: name of supervisor of division,section or <br /> TOTAL NUMBER OF TANKS 404 Is facility on an office which operates the UST. (This is the ontact person for the tank records.) <br /> REMAINING AT SITEf or trust lands? C��y <br /> f+ ❑Yes ®No <br /> II. PROPERTY OWNER INFORMATION <br /> 407. PHONE Z 409. <br /> PROPERTY OWNER NAME /�1 <br /> SW.4IQ,4A, C/7�C7(/f t/-� 7 409. <br /> MAILING OR STREET ADDRESS <br /> �03YTG-� Cf Oto 4u. ZIP CODE 412 <br /> ST <br /> CITY G,4 qs n <br /> �Cti/'„ V Ti� G� <br /> PROPERTY O�'tiER TYPE ON J�2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 413 <br /> ❑3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> III.TANK OWNER INFORMATION <br /> 414. 1 PHONE 415. <br /> TANK OWNERNAMEI,/Q (/_/��� 1 �J /J �Q� ��S.3 t <br /> _540 44AI _' "o,/,W. - V 416. <br /> MAILING OR STREET ADDRESS �O/C 1 �i+,a <br /> /'/ G/C 417 STAT a19. ZIP CODE�� / 419 <br /> CITY <br /> 5'ToTo� <br /> TANK OWNER TYPE ❑ 1.CORPORATION 2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY ago <br /> [13.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- <br /> Call 916 322-9669 if questions arise 421. <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ❑1.SELF-INSURED ❑4.SURETY BOND 7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM 422 <br /> 0 2.GUARANTEE 5.❑3.INSURANCE ❑6.EXEMPR OF TION ON CREDIT E 8.STATE FUND&CFO El 9-STATE FUND&CD LETTER E]99.OTHER: <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one box to indicate which address should be used for legal notifications and trailing. 2OWNER <br /> Legal notifications and mailings will be sent to the tank owner unless box 1 or 2 is checked. �l.FACILITY [12. PROPERTY OWNER [13. <br /> VII.APPLICANT SIGNATURE <br /> Certification: 1 certify that the information provided herein is true and accurate to the best of my knowledge.DATEPHSI ATURE OF APPLICANT AME OF APPLICANT(print) <br /> 426 TITLE OF APPLICANT STATE UST FACILITY NUMBER(Agency LLse only) 429 1998 UPGRADE CERTIFICATE NUMBER(Agency u <br /> (See Data Element 1,above. <br /> AUG 2 2004 <br /> UPCF Hwfwrc-a(1/99)-1/2 http://ww'w.unidoes.org Rev.02/16/00 <br /> ENVIRONMENT HEALTH <br /> MSERVICES <br />