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Aft <br /> IFIED PROGRAM CONSOLIDATED F0191W <br /> TANKS t <br /> UNDERGROUND STORAGE TANK - FACILITY <br /> (One page per site) Page of <br /> TYPE OF ACTION ❑1.NEW PERMIT 0 3.RENEWAL PERMIT e5.CHANGE OF INFORMATION [3 7.PERMANENTLY CLOSED SITE 4M1. <br /> (Check one item only) ❑4.AMENDED PERMIT(Specify change) ❑S.TANK REMOVED <br /> 6.TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION <br /> BUSINESS NAME(s m as FAcury NAME o qm-Doing Buri l=As) 3. FACILITY � t <br /> Flames t Qu?. 4 61+s <br /> NEAREST CROSS STREET 401. FACILITY OWNER TYPE L11.LOCAL AGENCY/DISTRICT' 401 <br /> 14---a <br /> ylr-1 Al.CORPORATION ❑5.COUNTY AGENCY* <br /> BUSINESS W.GAS STATION 0 3.FARM 0 5,COMMERCIAL 403• Q 2.INDIVIDUAL ❑6.STATE AGENCY" <br /> TYPE (]2.DISTRIBUTOR ©4.PROCESSOR [16.OTHER [13.PARTNERSHIP Q 7.FEDERAL AGENCY' <br /> TOTAL NUMBER OF TANKS 404. Is facility on Indian Reservation 405. 'If owner of UST is a public agenc)r.name of supervisor of division,section or 4% <br /> REMARflNG AT$iE or trust lands? office which operates the UST.(This is the contact person for the rank records.) <br /> )) ❑Yes o <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME /L�_/,�y 7 PIi �iE �/ 408. <br /> MAILING OR STREET ADDRESS /Q vI 409, <br /> V V <br /> CITY . 410• STATE � 411. ZIP CODE alz. <br /> PROPERTY OWNER TYPE ZI 1.CORPORATION 2.INDIVIDUAL 4.LOCAL AGENCY/DISTRICT 0 <br /> `6.STATE AGENCY 413. <br /> ©3.PARTNERSHIP ❑5.COUNTY AGENCY 0 7.FEDERAL AGENCY <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAMEf6r % �y 7��' i ter. PHONE �0 ars. <br /> MAILING OR STREET ADDRESS v'/ �� �%C{�4116 <br /> L�^-�- <br /> CITY � �% 417. STATE �/� � cls. ZIP CODE 419. <br /> t� <br /> TANK OWNER TYPE AL CORPORATION 2.INDIVIDUAL 4.LOCAL AGENCY/DISTRICT 6.STATE AGENCY 420. <br /> [j 3.PARTNERSHIP Q 5.COUNTY AGENCY ©7.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY TK H 44- Call 916 322-9669 if questions arise 42). <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ❑1.SELF-INSURED ❑4.SURETY BOND �❑7Q.STATE FUND [110.LOCAL GOVT MECHANISM 422 <br /> CI 2.GUARANTEE E35.LETTER OF CREDIT /9Z.STATE FUND&CFO LETTER []99.OTHER. <br /> ©3.INSURANCE 0 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 sett to the tank owner unless box 1 or 2 is checked. X I.FACILITY 0 2. PROPERTY OWNER ❑3.TANK OWNER 423. <br /> VII.APPLICANT SIGNATURE <br /> Certification: I certify that the info- herein is tote thra to the best of roy knowledge. <br /> SIGNATURE OF AFPLIC DATE �24. PHONE9 d'/- 425. <br /> /- <br /> NAME O PLiCANT t) aze TTfL OF APPLICANT Ori. <br /> uPin fz,� �� • 0neY <br /> STATE UST FACILITY NUMBER(Agency use onty) 429• 1998 UPGRADE CERTIFICATE NUMBER(Agency ase only) 429. <br /> (See Data Element 1,above. <br /> UPCF Hwfwre`a(1/99)-1/2 www.vaidemorg Rev,02/16100 <br />