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YIFIED PROGRAM CONSOLIDATED FIR ` TANKS UNDERGROUND STORAGE TANKS - FACILITY e� (One page per site) Page_of_ TYPE OF ACTION 1%I.NEW PERMIT ❑3.RENEWAL PERMIT [15.CHANGE OF INFORMATION ❑7.PERMANENTLY CLOSED SITE 400. (Check one item only) ❑4.AMENDED PERMIT (Specify change) ❑8.TANK REMOVED ❑6.TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3. FACILITY II ku 2- C A F►r lDftiCA4� 7� 1 � � � � I L NEAREST CROSS STREET A' ff 401. FACILITY OWNER TYPE ❑4.LOCAL AGENCY/DISTRICT- 402. �tZ.IL 713 !`�• GL Ya Jt{• t520 z ❑ I.CORPORATION ❑5.COUNTY AGENCY* BUSINESS qQ I.GAS STATION ❑3. FARM Lj 5.COMMERCIAL 403. JK2.INDIVIDUAL ❑6.STATE AGENCY* TYPE [-12.DISTRIBUTOR ❑4.PROCESSOR [-16.OTHER [:13.PARTNERSHIP ❑7.FEDERAL AGENCY* 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. REMAINING AT SITE or trust lands'? office which operates the UST. (This is the contact person for the tank records.) 3 ❑Yes 59 No II. PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407 PHONE 4os. rREO 1=-S rAKD I ArL OS - Fo 4- - � it 39 MAILING OR STREET ADDRESS 409, I O tZ t A•u-XE C.-T- CITY. 410. 1 STATE 411. 1 ZIP CODE 412. PROPERTY OWNER TYPE I.CORPORATION 2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT D 6.STATE AGENCY 413. ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY III.TANK OWNER INFORMATION TANK OWNER NAME 414. PHONE 415. Rio Es FA,L� I Arn 4o Fr- F-o 3 y MAILING OR STREET ADDRESS 416. 310 t A,u r.0T - CITY an. STATE 418. ZIP CODE 419. 'f�� F_a-s �-ray( C A, 9 yr 6 6 TANK OWNER TYPE. ❑ I.CORPORATION ®2.INDIVIDUAL ❑4.LOCAL AGENCY/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- 1 1 1 1 1 1 1 Call 916 322-9669 if questions arise 421. V.PETROLEUM UST FINANCIAL RESPONSIBILITY INDICATE METHOD(s) ❑ I.SELF-INSURED [14.SURETY BOND ®7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM 4„ [:12.GUARANTEE [15.LETTER OF CREDIT ❑8.STATE FUND&CFO LETTER ❑99.OTHER: ❑3.INSURANCE ❑6.EXEMPTION ❑9.STATE FUND&CD VI.LEGAL NOTIFICATION AND MAILING ADDRESS Check one box to indicate which address should be used for legal notifications and mailing. Legal notifications and mailings will be sent to the tank owner unless box I or 2 is checked. ❑ I.FACILITY ❑2. PROPERTY OWNER X 3.TANK OWNER 423. VII.APPLICANT SIGNATURE Certification: I certify that the information provided Perein is true and accurate to the best of my knowledge. SIGNATURE OF APPLICANT DATE // 424. PHONE 425 / _/ 03 rfl NAME OF APPLICANT(print) 426. TITLE OF APPLICANT 427 M(C(4 A-E l L T-0 14 C 0 xt-r'!Z A-F-TO n- STATE UST FACILITY NUMBER(Agency use only) 428. 1998 UPGRADE CERTIFICATE NUMBER(Agency use only) 421) (See Data Element 1,above. UPCF Hwfwre-a(1/99)-1/2 http://www.unidocs.org Rev.02/16/00