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11w 1)PROGRAM CONSOLIDATED FORM �� <br /> TANKS ., .r <br /> UNDERGROUND STORAGE TANKS -FA I4TY <br /> (onge pe site) Page_of_ <br /> 5.CHANGE OF DTORMATION ❑7.PERMANENTLY CLOSED SITE ° <br /> h7E OF ACTION �1.NEW PERMIT ❑3.RENEWAL PERMIT ❑ ❑e.TANK REMOVE) f <br /> ❑4.AMENDED PERMIT (Specify change) ` <br /> (Cbeck one item only) ❑6.TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION <br /> FACILITY 1 <br /> BIiSNESS NAME(Saca FAC'B.t7Y NAM1tEInB Bmines As) 3. r I <br /> G I �� FACILITY OWNER TYPE 4.LOCAL AGENCY/DISTRICT• 402 <br /> NEARESTCROSS TREET C {.CORPORATION ❑5.COUNTY AGENCY' <br /> 2.INDNIDUAL ❑6.STATE AGENCY- <br /> BUSNES .GAS STATION 3.FA 5.COMMERCIAL 403. ❑ T.FEDERAL AGENCY- <br /> TYPE PROCESSOR ❑6.OTHER ❑3.PARTNERSHIP ❑ <br /> hY•E ❑2.DISTRIBUTOR ❑ 405. If owner of UST is a public agency: etre¢of ctpc oor of division. COTdO or 4a6. <br /> TOTAL NUMBER OF TANKS aos. is facility on Indian Reservation office which opmm the UST (This is the coota[tpeeson for the tank sorts.) <br /> RENAINNG AT SITE or tout lands? <br /> 3 ❑Yes�No <br /> II. PROPERTY OWNER INFORMATION <br /> 407. PHONE 408. <br /> PROPERTY OWNER NAME <br /> !p409. <br /> M. ILNG OR STREET DAl RESS S1, 00/t/X LJ�^ r 010. STATE/J - at. ZIP COD aa. <br /> CITY � l C'l - ���D l <br /> C� 7EJ ata. <br /> PROPERTY OWNER TYPE .CORPORATION ❑3:ARTNERSHIP ❑5.COUNTY AGENCY STRICT ❑7.FEDERAL AGENCY <br /> M.TANK OWNER INFORMATION <br /> Ota. PHONE 415. <br /> TANKOWNER NAME <br /> MAILING OR STREET ADDRE�,• ^G nO/ O <br /> 4c ' G ,l 419 <br /> CITY 4t7. STATE <br /> G 4u. ZIP CODE �Z o <br /> © � <br /> azo <br /> RAT <br /> TANK OWN R TYPE <br /> L CORPOION 2.INDIVIDUAL 4.LOCAL AGENCY/DISTRICT 6.STATE AGENCY . <br /> ❑3.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) [3I.SELF-INSUSTATE i6.LOCAL GOVT MECHANISM 4u. <br /> RED ❑4.SURETY BOND ❑7.STATE FUND <br /> ❑3.NSURAN EC E [3 5.LETTER OF❑6.EXEMPTION CREDIT O O LETTER ❑99.OTHER: <br /> 9.STATE FUND&CD <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one box In indicate which address Should be used for legal notifieatiom wd marling. <br /> 4m- <br /> Legal notifimoom and railings will be sent m the mok owner unless box I or 2 is checked 1.FACILITY ❑2. PROPERTY OWNER ❑3.TANK OWNER <br /> VII.APPLICANT SIGNATURE <br /> Cenifintien: 1 certify that the information provided herein is true and accurate m the best of my knowledge. 424. PHONE 4Z5_ <br /> DATE <br /> SI RE OF LI T Zdi Q 63 S <br /> 427. <br /> 426. TITLE F PLICA <br /> E re429. <br /> use Only) 428. 1998 UPGRADE CERTIFICATE NUMBER(Agency uta On ) <br /> STATE UST FACILITY UMBER(Agmry O J-7 <br /> (See Data Element 1,above. C 5 <br /> c _ Zo M r Ste^ <br /> d° N Rev.02/16/W <br /> UPCF Hwfwrc-a(1/99)-1/2 http://www.unidocs.org <br />