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L: IFIED PROGRAM CONSOLIDATED FOR . <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (One page per site) Page of L <br /> �.�/ 61, <br /> TYPE OF ACTION ❑1.NEW PERMIT ❑3.RENEWAL PERMIT �.CHANGE OF INFORMATION ❑7.PERMANENTLY CLOSED SITE <br /> (Check one item only) <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) 3. FACILITY O <br /> LO -q-1 1 <br /> NEAREST CROSS STREFrT 401. FACILITY OWNER TYPE ❑4.LOCAL AGENCY/DISTRICT* a <br /> U� ❑ 1.CORPORATION ❑5.COUNTY AGENCY* <br /> BUSINESS 1.GAS STATION 3.FARM 5.COMMERCIAL 403. �2.INDIVIDUAL ❑6.STATE AGENCY* <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR [:16.OTHER ❑3.PARTNERSHIP ❑7.FEDERAL AGENCY* <br /> 404. 405. *]f owner of UST is a public agency:name of supervisor of division,section or aob. <br /> TOTAL NUMBER IT TANKS Is facility on Indian Reservation office which operates the UST. (This is the contact person for the tank records.) <br /> REMAINING AT SITE 2 or trust lands? � <br /> v ❑Yes E�No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME /� f �j 40��1112 <br /> L�/L�C� ; sem-//L� / : •�/ � S� - -/ U z 408 <br /> MAILING OR STREET ADDRESS 409 <br /> CITY Oto. 'STATE 411. ZIP CODE 412 <br /> s �o Gc i r��� G IFs- <br /> 0 0 <br /> PROPERTY OWNER TYPE ❑ 1.CORPORATION 2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 413. <br /> ❑3.PARTNERSHIP [15.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME _ r 414. PHONE ! z 415. <br /> 416. <br /> MAILING OR STREET ADDRESS <br /> CITY <br /> 15417. STATE 411. ZIP CODE 419. <br /> 7 o G i� i c�� <br /> TANK OWNER TYPE ❑ 1.CORPORATION 2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 4.0 <br /> [13.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- & Call 916)322-9669 if questions arise 421. <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ❑1.SELF-INSURED ❑4.SURETY BOND .12r7.STATE FUND ❑ 10.LOCAL GOV"f MECHANISM 422 <br /> GUA CE❑ CREDIT ❑ STATE FUND <br /> &CD LETTER ❑99.OTHER: <br /> 03. RAN6.EXEMPTION 9.STATE F <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one box to indicate which address should be used for legal notifications and mailing. 423 <br /> Legal notifications and mailings will be sent to the tank owner unless box 1 or 2 is checked. 9(1.FACILITY [:12. PROPERTY OWNER [13.TANK OWNER - <br /> VII.APPLICANT SIGNATURE <br /> Certification: I certify that the information provided herein is true and accurate to the best of my knowledge. 424 PHONE <br /> � 4�25. <br /> A <br /> PPLICANT DATE <br /> < 427.SI7 <br /> � <br /> - <br /> e7e N O (print / , 426 TITLE OF APPLICANT <br /> z <br /> STATE UST FACILITY NUMBER(Agency use only) <br /> 421. 1998 UPGRADE CERTIFICATE NUMBER(Agency use only) 479 <br /> (See Data Element 1,above. <br /> UPCF Hwfwrc-a(1/99)-1/2 http://www.unidocs.org Rev.02/16/00 <br />