Laserfiche WebLink
of <br /> FIED PROGRAM CONSOLIDATED FO (D/I6 <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY /B��j�� <br /> (One page per site) C - of <br /> TYPE OF ACTION ❑1.NEW PERMIT [13.RENEWAL PERMIT �5.CHANGE OF INFORMATION 400 <br /> Check one item only ❑7.PERMANENTLY CLOSED SITE <br /> ( ) ❑4.AMENDED PERMIT (Specify change) ❑8.TANK REMOVED <br /> ❑6.TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) FACILITY <br /> MktN STREET AkCO R M Q M- KJS EN�?ICLf ► ID# � I Ac- FF1 0 O O _1 IA-16 �41- <br /> NEAREST <br /> CROSS STREET 401 FACILITY OWNER TYPE ❑4.LOCAL AGENCY/DISTRICT* 402. <br /> S. Mh1N STP EE'T ❑ 1.CORPORATION ❑5.COUNTY AGENCY* <br /> BUSINESS PkI.GAS STATION ❑3.FARM ❑5.COMMERCIAL 403. ❑2.INDIVIDUAL ❑6.STATE AGENCY* <br /> TYPE Lj 2.DISTRIBUTOR [14.PROCESSOR ❑6.OTHER %3.PARTNERSHIP LLC, ❑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? office which operates the UST. (This is the contact person for the tank records.) <br /> �j ❑Yes 9No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE <br /> JF -v� tutePP�1sE Lt~L 408 <br /> �51�)Zg6-3410 <br /> MAILING OR STREET ADDRESS 409. <br /> (olF2NES LI4NE <br /> CITYSTATE 411. ZIP CODE 412 <br /> V-� Vt <br /> EbNT 410. C_Pt q4536 <br /> PROPERTY OWNER TYPE ❑ L CORPORATION ❑2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 413 <br /> LL G ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> III.TANK OWNER INFORMATION TA'w 1Z OPERA-TOL I N F'oRµhtl <br /> TANK OWNER NAME414. PHOrNE 415. <br /> VLJS eNte1LQL1sE LLC- baN MMN STREET Pk(.0 AM PM `2- EA g2S - C, 1$`i <br /> MAILING OR STREET ADDRESS 416. <br /> it o0 5. MAIM STP,EET <br /> CITY 417. rTATE als. ZIP CODE 419. <br /> M C_ C X 9 S 33-1 <br /> TANK OWNER TYPE ❑ 1.CORPORATION ❑2.INDIVIDUAL` ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 420. <br /> 3.PARTNERSHIP [:15.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 1 1 1 1 1 1 1 Call(916)322-9669 if questions arise 421 <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) [11.SELF-INSURED ❑4.SURETY BOND [:17.STATE FUND ❑10.LOCAL GOVT MECHANISM 422 <br /> [12.GUARANTEE ❑5.LETTER OF CREDIT 98.STATE FUND&CFO LETTER ❑99.OTHER: <br /> ❑ El3.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 I or 2 is checked. )�1.FACILITY ❑2. PROPERTY OWNER ❑3.TANK OWNER 423. <br /> VII.APPLICANT SIGNATURE <br /> Certification: I certify that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNATUU OX APPLICANT DATE 424. PHONE 425. <br /> i' 1,1x41 C2O'1) 8 2-5 Li <br /> NAME OF APPLICANT(print) 426. TITLE OF APPLICANT 427. <br /> KV1-D-EP C , SHARMA. M""G-L1 C-Eb <br /> STATE LIST FACILITY NUMBER(Agency use only) 428 1998 UPGRADE CERTIFICATE NUMBER(Agency use only) 429. <br /> (See Data Element I,above. <br /> UPCF Hwfwrc-a(1/99)-1/2 http://www.unidocs.org Rev.02/16/00 <br />