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F� <br /> D PROGRAM CONSOLIDATED FO ,,(� p1) Rj" <br /> ' TANKS <br /> UNDERGROUND STORAGE TANKS - FACILIoTYge Per site) Page_of <br /> CHANGE OF INFORMATION ❑7.PERMANENTLY CLOSED SITE 400. <br /> TYPE OF ACTION ❑1.NEW PERMIT ❑3.RENEWAL PERMIT � ❑g.TANK REMOVED n D <br /> (Check one item only) ❑4.AMENDED PERMIT (Specify change) \�vf <br /> ❑6.TEMPORARY SITE CLOSURE p <br /> I. FACILITY/SITE INFORMATION 175 <br /> BUSINESS NAME(Sam asFACILITY NAME orDBA-Doing Business As) 3. FACILITY 1. 11� <br /> I <br /> NEAREST C S STREET s 4o1. FACILITY OWNER TYPE 4.LOCAL AGENCY CES <br /> 4v <br /> ❑1.CORPORATION ❑5.COUNTY AGENCY* PERi�ITIS� <br /> BUSINES 1.GAS TATION 3.FARM 5.COMMERCIAL 403 2.INDIVIDUAL 6.STATE AGENCY* <br /> TYPE ❑2.DISTRIBUTOR [14.PROCESSOR [16.OTHER ❑3.PARTNERSHIP ❑7.FEDERAL AGENCY* <br /> 406 <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 <br /> or trust lands? office which operates the UST. (This is the contact person for the tank records.) <br /> REMAINING AT SITE �I' <br /> ` 5T ❑Yes P No <br /> II. PROPERTY OWNER INFORMATION <br /> 407. p NE 408, <br /> PROPERTY OWNER NAME <br /> - Zc,� - <br /> 409. <br /> MAILING OR STREET ADDRESS <br /> � 410STATE <br /> �411. ZIP CODE 412. <br /> CITY V 37 <br /> 413. <br /> PROPERTY OWN TYPE ❑ 1.CORPORATION 2.INDIVIDUAL <br /> TNERSHIP 5.COUNTY AGENCY <br /> ❑Li 7 <br /> .STATE AGENCY <br /> [13.PARTNERSHIP ❑ .FEDERAL AGENCY <br /> III.TANK OWNER INFORMATION <br /> 114 N 415, <br /> T NK OWNER NAME, <br /> 416. <br /> MAILING OR STREE AD ESS <br /> 417. STATE ale. ZIP CODE 419_ <br /> CIT <br /> � � <br /> TANK OWNER TYPE 1.CORPORATION 2.INDIVIDUAL 4.LOCAL AGENCY/DISTRICT 6.STATE AGENCY ago- <br /> 3.PARTNERSHIP ❑5.COUNTY AGENCY [17.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY TK H 44- 2- <br /> Call 916)322-9669 if uestions arise 421. <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ❑1.SELF-INSURED ❑4.SURETY BOND ❑7.STATE FUND ❑to.LOCAL GOVT MECHANISM qu, <br /> LETTER❑3.INSURANCE ❑6.EX MPT ON CREDIT 0 9.STATE FUND&CD LETTER ER ❑99.OTHER: <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one box to indicate which address should be used for legal notifications and mailing. q , <br /> Legal notifications and mailings will be sent to the tank owner unless box 1 or 2 is checked. i'1.FACILITY [12. PROPERTY OWNER ❑3.TANK O WNER <br /> VII.APPLICANT SIGNATURE <br /> Certification: I certify that the information provided herein is true and accurate to the best of my knowledge. azo. PHONE 425. <br /> SIGNATU F APP CANT DATE <br /> 426. TITLE OF APPLICANT 427. <br /> •NAME O OF APPLICANT( tint) <br /> r en' TA Cl) <br /> STATE UST FACILITY NUMBER(Agency use only) <br /> 425. 1 UPGRADE CERTIFICATE NUMBER(Agency use only) a29. <br /> (See Data Element 1,above. <br /> P' <br /> UPCF Hwfwrc-a(1/99)-1/2 <br /> http://www.unidocs.org Rev.02/16/00 <br />