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FIED PROGRAM CONSOLIDATED FORM PR# FAC# UNDERGROUND STORAGE TANKS -FACILITY (one page per site) YPE OF ACTION l NEW SITE PERMIT ❑ 3 RENEWAL PERMIT © 5 CHANGE OF INFORMATION ❑ f PERMANENTLY CLOSED SI fE Check one nem only) 4 AMENDED PERMIT aped c Ioealuse E] rt � � .T �� ❑ 8 TANK REMOVED f-1 6 TEMPORARY SITE CLOSURE 400 I FACILITY/SITE INFORMATION BUSINESS NAME(same as FACILITY NAME or DBA Doing Business As) g FACILITY ID# PR IDH 0 r)I 1 r&1' 1,74--fra I ` NEARS CROSS STREET FACILITY OWNER TYPE 401 ❑ 4 LOCALAGENCYIDISTRICT• fOr^ R I CORPORATION BUSINESS C:12 INDIVIDUAL TYPE E:1 S COUNTYAGENCY• ❑ I GAS STATION ❑ 3 FARM El 5 COMMERCIAL ❑ 6 STATE AGENCY• 402 ' 2 DISTRIBUTOR 4 PROCESSOR 5 OTHER 403 © 3 PARTNERSHIP ❑ ❑ ❑ 6 FEDERAL AGENCY• TOTAL NUMBER OF TANKS Is facility on Indian Reservation or •Ifowner of UST is a pubbc agency name of supervrsor of division section or office which operates REMAINING AT SITE trustlands9 the UST(This is the contact person for the tank records) f 404 ❑ Yes [9 No 405 406 II PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407 PHONE 40e Uq 1 Ers+- Lor on N 20", Cl"/ -S -3E MAILING OR STREET ADDRESS 409 01-19 14 v n `-ef S'¢ . ' CITY 410 STATE 411 ZIP CODE 412 S fo,✓It o n c R QsZo�t PROPERTY OWNER TYPE [� 1 CORPORATION ❑ 2 INDIVIDUAL ❑ 4 LOCAL AGENCY I DISTRICT ❑ 6 STATE AGENCY ❑3 PARTNERSHIP ❑ 5 COUNTY AGENCY 1:17 FEDERAL AGENCY 413 ' III TANK OWNER INFORMATION TANK OWNER NAME 414 PHONE 415 0A1 P7Ir5f C. drm�10rn AILING OR STREET ADDRESS 416 - CITY i Q G 614 STATE C R- 418 ZIP CODE ZO 419 °l5 � TANK OWNER TYPE CM-1 CORPORATION ❑ 2 INDIVIDUAL ❑ 4 LOCAL AGENCY I DISTRICT ❑ 6 STATE AGENCY 420 ❑ 3 PARTNERSHIP ❑ 5 COUNTY AGENCY ❑ 7 FEDERAL AGENCY IV BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY(TK)HQ 44- Call(916)322-9669 If questions arise 421 V PETROLEUM UST FINANCIAL RESPONSIBILITY INDICATE METHOD(s) I SELF-INSURED ❑4 SURETY 13OND ❑ 7 STATE FUND ❑ to LOCAL Gov r MF,CHANISM ©2 GUARANTEE ❑5 LETTLR OF CREDIT ❑ 8 STATE FUND&CFO LETTER 1199 OTHER ' ❑ 3 INSURANCE ❑6 EXEMPTION ❑ 9 STATE FUND&CD 422 t VI LEGAL NOTIFICATION AND MAILING ADDRESS ' Check one box to indicate which address should be used for legal notifications and mailing. I F CILIT ❑2 >PPERTY OWNER ❑ 3 TANK OWNER 423 Legal nonficattons and mailing will be sent W the tank owner unless box I or 2 1s checked VII APPLICANT SI NA Certification I certify that the mforma provided herein is true and accurate to the best or my knowledge SIGNATURE OF A DATE 424 PHONE 425 /z /1r7- o '? I 7fCy - 6t 7L-Z3ov NAME OI ��IICANT(print) 426 TITLE OF APPLI ANT 424 l vrar+t 2�,e ' (/1 G e_ p res(d. ATE UST FACILITY NUMBER(For local ue only) 428 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 ' Is 1998 Compliant? UPCF(1/99 revised)