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oxx Gamma= <br /> IN V <br /> Now <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (One page per site) Page_of_ 1 <br /> TYPE OF ACTION (3 1.NEW PERMIT ❑3.RENEWAL PERMIT C3 5.CHANGE OF INFORMATION ❑7.PERMANENTLY CLOSED SITE C) \ <br /> (Chock one item only) E3 4.AMENDED PERMIT (Specify change) ❑8.TANK REMOVED <br /> 6.TEMPORARY SITE CLOSURE _ � <br /> I. FACHdTYISITE INFORMATION f�W���_ <br /> -T <br /> BUSINESS NAME( as FACILRY NAME or DDA-Domg Buses As) 3. FACILITY <br /> �•rk� - 1. <br /> AREST CROSS STREET 4o1. FACILITY OWNER E 4.LOCAL AGENCY/DISTRICT' 402• <br /> ,LO 131.CORPORATION [❑5.COUNTY AGENCY' 0� <br /> BUSINESS,W 1.GAS STATION 3.FARM 5.COMMERCIAL P,2.INDIVIDUAL ❑6.STATE AGENCY' �19 I <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR ❑6.OTHER ❑3.PARTNERSHIP ❑7.FEDERAL AGENCY' <br /> 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. <br /> REMAINING AT SITE or trust lands? office which operates the UST. (This is the contact person for the tank records.) <br /> ❑Yes P&No <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER N 407 PHONE 40s. <br /> 1I S0- s�/Y <br /> ING OR STREET ADDRESS 409• <br /> d - <br /> CITY 410 STATE 411 ZIP CODE 412. <br /> ./ <br /> PROPERTY TYPE U 1.CORPORATION VAR MODRDUAL U 4,LOCAL AGENCY/DISTRICT U 6,STATE AGENCY 413.. <br /> 3.PARTNERSHIP 5.COUNTY AGENCY 7.FEDERAL AGENCY <br /> HI.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> MAIL R STREET ADDRESS 416. <br /> CITY 417. STATE 419. 1 ZIP CODE 419. <br /> TANK OWNER TYPE 131.CORPORATION 2.INDIVIDUAL 4.LOCAL AGENCY/DISTRICT L3 6.STATE AGENCY 420. <br /> 3.PARTNERSHIP .COUNTY Y A TICY 7,MDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION USS'STORAGE FEE ACCOUNT NUMBER <br /> TY TK 1I 44- Call 916 322-9669 if guestions adso 421. <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ❑1.SELF-INSURED C)4.SURETY BOND ❑7.STATE FUND ®10.LOCAL GOVT MECHANISM 422 <br /> ❑2.GUARANTEE S.LEI-IFR OF CREDIT S.STATE FUND&CFO LETTER ®99,OTITER; <br /> >a4WRAb= &EXEMI�'i(iAi g 9.STATE FUN"CO <br /> VI,LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Chook ono Wx to Ivdiam whisk addteaa*900 be vied thr lept�l nottficattoiss 04 tnaiTitlg. <br /> Legit notifications and mailings will be sent to the tank owner unless box 1 or 2 is checked. ® 1.FACILITYPROPERTY OWNER ®3.TANK OWNER 423- <br /> VII,APPLICANT SIGNATURE <br /> Certification:I certify that the informatica provided herein is true and accu dle to the best of my knowledge. - <br /> TURE OF APPLIC DATE 424 PHONE azs. <br /> OF APPLICANT(print) 426. TITLE OF APPLICANT 427. <br /> ly- , <br /> STATE U FAC rTY NUMBER(Agency use colt') 428- 1998 UPGRADE CERTIFICATE NUMBER(Agency use only) 429• <br /> (See Data Element 1,above. <br /> UPCF Hwfwm-a(1/99)-IR http:/Avww.unklocs.org Rev.02/16/00 <br />