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U IED PROGRAM CONSOLIDATED M , l�`�'LI ` <br /> TANKS {-~'� 0 4 2007 <br /> UNDERGROUND STORAGE TANKS - FA"I,n I�r,"""' 't"HEAL,N (onepagepersite) <br /> Page _ of <br /> TYPE OF ACTION ❑1.NEW SITE PERMIT ❑3.RENEWAL PERMIT 05.CHANGE OF INFORMATION(Specify change- ❑7.PERMANENTLY CLOSED SITE <br /> (Check one item only) ❑4.AMENDED PERMIT local use only) ❑8.TANK REMOVED 400 <br /> ❑6.TEMPORARY SITE CLOSURE <br /> 1,FACILITY F SITE INFORMATION <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 FACILrrY ID# = 1 <br /> BUSINESS SITE ADDRESS 401 FACILITY OWNER TYPE <br /> 4. LODISTRICT' <br /> 5. COUNTY A <br /> 2701 W MARCH LN ❑ 1. CORPORATION ❑ NTYAGENCY- <br /> 2. INDIVIDUAL ❑ <br /> BUSINESS TYPE ®1.GAS STATION ❑ 3.FARM ❑5.COMMERCIAL 3. PARTNERSHIP ❑ 6. STATE AGENCY' <br /> ❑ 7. FEDERAL AGENCY' 402 <br /> ❑2.DISTRIBUTOR ❑ 4.PROCESSOR ❑ 6.OTHER <br /> 403 <br /> TOTAL NUMBER OF TANKS Is facility on Indian Reservation or 'If owner of UST is a public agency:name of supervisor of <br /> REMAINING AT SITE trustlands? division,section or office which operates the UST. <br /> (This is the contact person for the tank records.) <br /> 3 404 ❑Yes ®No 405 406 <br /> IL PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408 <br /> MAILING OR STREET ADDRESS le 409 <br /> CITY 41 STATE 411 ZIP CODE 412 <br /> PROPERTY OWNER TYPE <br /> 2. INDIVIDUAL ❑ 4. LOCAL AGENCY/DISTRICT ❑ 6. STATE AGENCY 413 <br /> ❑ 1. CORPORATION 3. PARTNERSHIP ❑ 5. COUNTY AGENCY ❑ 7. FEDERAL AGENCY <br /> I <br /> Ill.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 <br /> tMONA <br /> MAILING OR STREET ADDRESS 41 <br /> CITY 417 ST E 418 ZIP CODE 419 <br /> TANK OWNER TYPE 2. INDIVIDUAL ❑ 4. LOCAL AGENCY/DISTRICT ❑ 6. STATE AGENCY 420 <br /> ❑ 1. CORPORATION 3. PARTNERSHIP ❑ 5. COUNTY AGENCY ❑ 7. FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> 421 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(S) ❑ 1. SELF-INSURED ❑ 4. SURETY BOND 5L7. STATE FUND ❑ 10. LOCAL GOV=T MECHANISM <br /> &2. GUARANTEE ❑ 5. LETTER OF CREDIT ❑ 8. STATE FUND&CFO LETTER ❑99. OTHER: <br /> 3. INSURANCE ❑ 6. EXEMPTION ❑ 9. STATE FUND&CD 422 <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one box to indicate which address should be used for legal notifications and mailing. ❑ 1. FACILITY ❑ 2. PROPERTY OWNER ® 3. TANK OWNER 423 <br /> Legal notifications and mailings will be sent to the tank owner unless box 1 or 2 is checked. <br /> VII.APPLICANT SIGNATURE <br /> Certification: ify that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNATU APPLICANT DATE 424 PHON 425 <br /> ccz <br /> NAME 0 APPLICANT(print) TITLE OF LICANT 26 <br /> STATE UST FACILITY NUMBER(For local use only) 427 1 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 428 <br /> UPCF(1/99 revised) 5 Formerly SWRCB Form A <br />