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IFIED PROGRAM CONSOLIDATED FORW <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (One page per site) Page-L of-5_ <br /> TYPE OF ACTION K1.NEW PERMIT ❑3.RENEWAL PERMIT ❑5.CHANGE OF INFORMATION ❑7.PERMANENTLY CLOSED SITE 400. <br /> (Check one item only) ❑4.AMENDED PERMIT(Specify change) ❑8.TANK REMOVED <br /> ❑6.TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Same asFACILITY NAW orDBA-Doing Business M) 3. FACILITY <br /> �4U 'L mint-McLr4 w-6as ID# ,. <br /> NEAREST CROSS STREET 401. FACILITY OWNER TYPE ❑4.LOCAL AGENCY/DISTRICT* 4oz. <br /> kp&eMaf'e- La-ne.,, ❑1.CORPORATION [:15-COUNTY AGENCY* <br /> BUSINESS al.GAS STATION [:13.FARM ❑5.COMMERCIAL 403• E12.INDIVIDUAL [:16.STATE AGENCY* <br /> TYPE [:12.DISTRIBUTOR [:14.PROCESSOR [16.OTHER &3.PARTNERSHIP [17.FEDERAL AGENCY* <br /> TOTAL NUMBER OF TANKS 404. Is facility on Indian Reservation 405. '1f owner of UST is a public agency:nava'of supervisor of division,section or 406. <br /> REMAINING AT SITE or trlrSt lands? office which operates the UST. (This is the contact person for the tank records.) <br /> ❑Yes [j'No <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. 1 PHONE 408. <br /> a* Pam; I L-I-J . aO9- 45I-/;t-0-7 <br /> MAILING OR STREET ADDRESS <br /> ro k-e J S-R c.k_ Ci reI e, 4 <br /> CITY G alo. STATE G,^ 411 ZIP CODE_ KZ' Cf 4,z12. <br /> PROPERTY OWNER TYPE 0 1.CORPORATION 2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT 0 6.STATE AGENCY 413. <br /> PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> as <br /> MAILING OR STREET ADDRESS 416. <br /> CITY 41 STATE 418. ZIP CODE 419. <br /> TANK OWNER TYPE ❑1.CORPORATION [12-INDIVIDUAL [14.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY azo. <br /> ❑3_PARTNERSHIP ❑5.COUNTY AGENCY [17.FEDERAL AGENCY <br /> .BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 1 1 1 1 1 1 1 Call(916)322-9669 if questions arise 421. <br /> .PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ❑1.SELF-INSURED ❑4.SURETY BOND 07.STATE FUND 1110.LOCAL GOVT MECHANISM 422 <br /> ❑2.GUARANTEE ❑5.LETTER OF CREDIT ❑8.STATE FUND&CFO LETTER ❑99.OTHER: <br /> [:13.INSURANCE ❑6.EXEMPTION ❑9.STATE FUND&CD <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one box to indicate which address should be used for legal notifications and mailing. <br /> Legal notifications and mailings will be sent to the tank owner unless box I or 2 is checked. ❑ 1.FACILITY 22. PROPERTY OWNER [13.TANK OWNER 423 <br /> 04-PPLICANT SIGNATURE <br /> Certifi ' n: I cern that the information provided herein is true and accurate to the best of my knowledge. <br /> S71144 ;rPPL7;7k'W DATE5-_/5" O3 4� PHONE azs. <br /> -iT ' <br /> AME OF APP !CANT(print) 426. TITLE OF APPLICANT 427 <br /> (,"',r a+ D ujll s- l <br /> STATE UST FACILITY NUMBER(Agsncyuw oniy) 428. 1998 UPGRADE CERTIFICATE NUMBER(Agcncyuwonly) 429. <br /> (See Data Element 1,above. <br /> UPCF Hwfwrc-a(1/99)-1/2 http://www.unidocs.org Rev.02/16/00 <br />