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1-0IED PROGRAM CONSOLIDATED FOR <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (One page per site) Pa f <br /> rYPE OF ACTION ❑ I.NEW PERMIT ❑3.RENEWAL PERMIT �5.CHANGE OF INFORMATION ❑till TLY CLOSED SlllE rr 400. <br /> (Check one item only) ❑4.AMENDED PERMIT (Specify change) ❑8.TANK REMOVED,,n i� t <br /> ❑6.TEMPORARY SITE CLOSURE ` I <br /> µ!L la <br /> I. FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Same m FACILITY NAME or DBA-Doing Business As) FACILITY <br /> MMU S'CREI;T AkCo A nn P M- KJS EN1tcLP S ID# ps- 0 b F7' (D 1-1 [+T6 41. <br /> NEAREST CROSS STREET 401 FACILITY OWNER TYPE [14.LOCAL AGENCY/DISTRICT* 401 <br /> S• MMw STP LET M KM TEC-A ❑ 1.CORPORATION ❑5.COUNTY AGENCY* <br /> BUSINESS I.GAS STATION ❑3.FARM ❑5.COMMERCIAL 403. ❑2.INDIVIDUAL ❑6.STATE AGENCY* <br /> TYPE 2.DISTRIBUTOR [j4.PROCESSOR ❑6.OTHER 3.PARTNERSHIP �"L ❑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 /> 3 ❑Yes 9No <br /> II. ,PROPERTY�OWNERINFORMATION . <br /> PROPERTY OWNER NAME 407. PHONE 408. <br /> JEsV.UL. tuTGLS1Q)Z`{6-3LiI <br /> MAILING OR STREET ADDRESS 409. <br /> (o-I �h1ZN E S L ArNE <br /> CITY 410, [STATE 411. ZIP CODE 412, <br /> r-4LEMoNT ca 14536 <br /> PROPERTY OWNER TYPE ❑ 1.CORPORATION ❑2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 413. <br /> LL G ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> - IILTANK OWNER INFORMATION �aN l� OPERMT0Q. 1 iJ r�RµIMTI <br /> TANK OWNER NAME ala. PHONE 415. <br /> ILJS eNCeaP�.tsE LLC- bad MAIN S-TI.EET 0,kLo Krol PM (2.,n,-) 27-S- (.,1$y <br /> MAILING OR STREET ADDRESS 41fi. <br /> 1100 S. MAIN S-T G_E-T <br /> CITY 417. 1 STATE 418. ZIP CODE 419. <br /> MNr zlrLPc C1� 95331 <br /> TANK OWNER TYPE ❑ 1.CORPORATION ❑2.INDIVIDUAL Lj 4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 420. <br /> 3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> IV. <br /> BOARD OF EQUALIZATION UST.STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- O Call(916)322-9669 if questions arise 42t. <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 /> ❑2.GUARANTEE ❑5.LETTER OF CREDIT8.STATE FUND&CFO LETTER ❑99.OTHER: <br /> ❑3.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 /> SIGNATU APPLICANT DATE 424. PHONE 425. <br /> _ �� <br /> 'Ll IIaI 0209) <br /> 42r, 'Tt_ U .PPL! ANi 427 <br /> NAF: . <br /> ` C•-,73 <br /> .TATE UST FACILITY NUMBER(Agency use only) 428. 1998 UPGRADE CERTIFICATE NUMBER(Agency use only) 429. <br /> (See Data Element 1,above. <br /> UPCF Hwfwrc-a(1/99)-1/2 http://www.unidoes.org Rev.02/16/00 <br />