Laserfiche WebLink
T'' n PRnr.RA d"o7,s01,IDATFD FORM <br /> I TCS <br /> UNDERGROUND STORAGE TANKS S - FACILITY <br /> (one a per sate) Page_•,.Y,of____ <br /> 7 YPE OP ACTION ® T NF,W SITE PE-57 ❑3.RENEWAL PERMTI' S.CIIANGE OF RYFORMATION 7.PERMANENTLY CLOSED SITE, <br /> (Check ow inn only) ❑4.AMEM'DEO PERMIT specifychamse local alae only-_ ❑ S.TANKRBMt3Vffi,D <br /> ® <br /> d.TMAPORARY SITE CLOSURE 400 <br /> 1. FACILITY f SITE INFORMATION <br /> BUSINESS NAME(suns as FACILITY NAW or DBA-Dwim auwm As) . 3 FACILCTY m#4 ay T/R G I v fds FA�D �, ` <br /> NEAREST CROSS S ET 401 FACILITY OWNER TYPE 4.LOCAL AGENCY/DID-MCT' <br /> C®ISMr-i Cv& SIVID PrASAu,eLS-_AA.:. ❑ 1.CORPORATION 5.COUNTY AGENCY* <br /> BUS S I.GAS STATION L1 3.PARM 5. CO C1AL K 2.INDIVIDUAL ❑6.STATE AGENCY* <br /> TYPE 2.DISTRIBUTOR Q 4.PROCESSOR®6. OTHER 40.1 3.PARTNERStUP Cj 7.FEDERAL.AGENCY* <br /> TpTaL NUMBER OF TANKS Is facility an Indian Reservation or .If owner of UST is a public agency:mane ofof division°sesaonor office whnstr <br /> REMAINING AT SITE nvs 7 op mes the UST(This is the contact paim for die tack moorda.) <br /> UST ae 0 Yrs No 40 iV 406 <br /> U. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 4at 1 PHONE _ 40 <br /> MAILING OR STREET ADDRESS 40 <br /> �-t <br /> CITY 410 ST411 ZIP CODE 4t2 <br /> PROPERTY OWNER w-lPF i.CORPORATIOAt -. INDI°a'InUAL 4.LOCAL AGENCY;DiS'IRICT 6.STATE AGENCY <br /> 0 3.PARTNERSIIIP Q 5.COUNTY AGENCY ®7,FEDERAL AGENCY 413 <br /> ui.TA,mK OWNER E INFORMATION <br /> TANK OWNER.NAME L; _ -4I4 PHONE :9917 415 <br /> llR STREET ADDRESS <br /> C a' <br /> 417 STATE Ott ZIP CODE 419 <br /> TANK OWNER�TYPE 1.CORPORATION 2.INDIVIDUAL 4.LOCAL AGENCY I DISTICICI'- 6.STATE XGENCY 420 <br /> ®3.PARTNEI IiIP []5.COUNTY AGENCYC1 7.FEDIEN.AL AGENCY <br /> IV.BOARD OF EQUALIZATION[IST STORAGE FEE ACCOUNT T ER <br /> . <br /> Ty TIC M 44 �� � Ca11{916)322-9669 if questims arise <br /> V.PI OLEO UST FINANCIAL ' SPONSIRII.ITY <br /> INDICATE MET7HOD(s) 0 1.SELF-INSURER ®4.SURETY BOND7.STATE FUND � lo.LOCAL GOVT WCHMLSM <br /> Q 2.GUARANTEE ❑5.LETTER OF CREDIT'*&STATE FUND&CFO LETTER 0 ".OTHER: <br /> C3 3.INSURANCE []&EXEMPTION [,9.STATE FUND&CD 4� <br /> VI.LEGAL NOTIFICATION AND MAMWG ADDRESS <br /> Check ono box to iudicau*hick 4d4auss should be used for legal notifications and atailing. _e - <br /> Lcgal coumons and tailings will be Stat to the tack owner ualsss box S.or 2 is checked. ❑ 1.FACMITY PROPER I Y OVINER_❑3.TAVK OWNER � 423 <br /> VII.APPLICANT SIGNATURE <br /> C FA w-i tits a on p h cin'Sand"accurate to the bestof my lcdge. � ^� <br /> s <br /> _S AP [ DA 424 <br /> N O LI (pranfl T r OF APPLICANT427 <br /> • �,, d• yyf`6sIQ�°-d� �` A�qn•os 14 r der+ov <br /> Ekf- <br /> STATE UST FACILITY NUMBER(For kew m oar,•) 426 1995 UPG E C IFICATE: ER( i ..ly) °W <br /> UPCF(1/99 revised) 8 Fonnerly SWRCB Foran A <br />