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D PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - F (pnepage per site)' <br /> 1 NEW PERMIT 3,RENEWAL PERMIT ❑S.CHANGE OF INFORMATION ❑7.PERMANENTLY CLOSED S< 40 <br /> TYPE OF ACTION [3 8.TANK REMOVED <br /> (Check orw iwm only) ❑4.AMENDED PERMIT (Specify change) <br /> ❑6.TEMPORARY SITE CLOSURE <br /> I. FACILTI'Y/SITE INFORMATION <br /> FACILITY 1. <br /> BUSINESS NAME(samea FACWTY N, ° DIIgBvabws Aa) J. IDN <br /> Gt 401. FACILITY OWNER TYPE Lj 4.LOCAL AGENCY/DISTRICT* 402. <br /> NEAREST CROSS TREE T O N. �' J.CORPORATION ❑5.COUNTY AGENCY- <br /> K X11 6.STATE AGENCY- <br /> BL'SAIES .GAS STATION 3.FA 5.COMMERCIAL 403. ❑2•INDIVIDUAL ❑7 FEDERAL AGENCY' <br /> TYRE 2.DISTRIBUTOR ❑4.PROCESSOR ❑6.OTHER ❑o PARTNERSHIP supervisor 406 <br /> 4W. Is facility on Indian Reservation 406. •o owner is UST u a public agency:Dame of s r of the tans seccoo or <br /> TOTAL NUMBER OF TANKS or vast lands? office which°���Ute' (T�s is the contact person for the tank recordz) <br /> REMAINING AT SITE Cp F`4r�. <br /> v2 Yes)eNo <br /> IL PROPERTY OWNER INFORAL�TION <br /> 407 PHONE 408, <br /> PROPERTY OIWTCN �� C Q �j S <br /> /O 409. <br /> \L ILMG OR STREETDRESS C �O• �'lO/t <br /> G4' STATE 4u. ZIP CO" 412. <br /> CITY -� j /'Al. � J ..Z� Z <br /> 413. <br /> PROPERTY OWNER TYPE .CORPORATION 02.[NDIVIDUAL L_I 4.LOCAL AGENCY/❑3.PARTNERSHIP ❑5.COUNTY AGENCYD� CT ❑7.FEDERAL AGENCY <br /> M.TANK OWNER INFORMATION <br /> 414. PHONE 415. <br /> TaNKOWNERNAME <br /> 416. <br /> MAILING OR STREET ADORE/. D <br /> e' an �. STATE 4m ZIP CODE re- <br /> CITY' f 'Z- L <br /> TANK OWNER TYPE .CORPORATION 0 3:ARTNERSHIP C 5.COUNTY AGGENC�ISTRICT ❑7.FEDERAL AGENCY ATE AGENCY am <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY TK)H 44- <br /> Call(916 I322-9669 if questions arise 421. <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) O 2 GUARANTEE 5.LETTER O4.SURETY f CREDIT El 8.STATE FUND&CFO LETTER E]99.OTHER: <br /> GOVT MECHANISM 4u. <br /> ❑1.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. �-FACILITY 423 <br /> amm . <br /> Legal wti6 ,and nvlings will be sent to the tank owner unless box 1 or 2 u e1w.k.1/ ❑2. PROPERTY OWNER <br /> II. ❑3.TANK OWNER <br /> VAPPLICANT'SIGNATURE <br /> Certification: I certify that the information PTO ded herein h true and a maw to the bat of my knowledge. 424. PHONE 425, <br /> SI RE OF P C DATE <br /> 426. TITLE F PLICA <br /> 429. <br /> s28.b 1998 UPGRADE CERTIFICATE NUMBER(Agency use onb) <br /> STATE UST FACILITY UMBER(Agenry,On�Y) J <br /> (See Data Element 1,above.. {_ 57 <br /> UPCF Hwfwrc-a(1199)-1/2 <br /> http://www.unidocs.org Rev.02116/00 <br />