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Us IED PROGRAM CONSOLIDATED FO <br /> TANKS <br /> E: UNDERGROUND STORAGE TANKS - FACILITY <br /> (One page per site) Page_of <br /> TYPE OF ACTION [11.NEW PERMIT ❑3.RENEWAL PERMIT ®5.CHANGE OF INFORMATION [17.PERMANENTLY CLOSED SITE 400. <br /> (Check one item only) ❑4.AMENDED PERMIT (Specify change) remote fill abandonment ❑8.TANK REMOVED <br /> ❑6.TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3. FACILITY <br /> ConocoPhilli s 2611194 2375 Trac Blvd. Trac CA ID# LI <br /> NEAREST CROSS STREET 401. FACILITY OWNER TYPE ❑4.LOCAL AGENCY/DISTRICT* aoz. <br /> Grant Line Road. Z 1.CORPORATION ❑5.COUNTY AGENCY* <br /> BUSINESS E9 1.GAS STATION [13.FARM ❑5.COMMERCIAL 403. [:12.INDIVIDUAL ❑6.STATE AGENCY* <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR ❑6.OTHER ❑3.PARTNERSHIP ❑7.FEDERAL AGENCY* <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 406. <br /> REMAINING AT SITE or trust lands? office which operates the UST. (This is the contact person for the tank records.) <br /> 4 ❑Yes ®No <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE aoa. <br /> ConocoPhilli s 916 558-7649 <br /> MAILING OR STREET ADDRESS 409. <br /> 76 Broadway, <br /> CITY 410 STATE all. 1 ZIP CODE alz. <br /> Sacramento,CA CA 95818 <br /> PROPERTY OWNER TYPE Z 1.CORPORATION 2.INDIVIDUAL 4.LOCAL AGENCY/DISTRICT Lj 6.STATE AGENCY 413. <br /> ❑3.PARTNERSHIP [15.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> III. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> SAME AS SECTION II <br /> 416. <br /> MAILING OR STREET ADDRESS <br /> CITY a17. STATE 418. ZIP CODE 419. <br /> TANK OWNER TYPE ® 1.CORPORATION ❑2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY ago. <br /> [:13.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY TK HQ 44- 1 1 1 1 1 1 Call 916 322-9669 if questions arise 421. <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ®1.SELF-INSURED ❑4.SURETY BOND ❑7.STATE FUND [110.LOCAL GOVT MECHANISM 422 <br /> ❑2.GUARANTEE ❑5.LETTER OF CREDIT ❑8.STATE FUND&CFO LETTER ❑99.OTHER: <br /> ❑3.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 1 or 2 is checked. ® 1.FACILITY ❑2. PROPERTY OWNER [:13.TANK OWNER 423. <br /> VII. APPLICANT SIGNATURE <br /> Certification: I certify that the info tion provided herein is true and accurate to the best of my knowledge. <br /> TU OF AP LIC DATE aza. PHONE 425. <br /> 707 789-3255 <br /> Z=<:::A �i ff <br /> NAM OF PLICAN t) 426. TITLE O APPLICANT 422 <br /> E ' Janzen- g f coPhillips Gettler-Ryan Inc. <br /> STATE UST FACILI NUMBER(Agency use only) 428 1998 UPGRADE CERTIFICATE NUMBER(Agency use only) 429• <br /> (See Data Element 1,above. <br /> UPCF Hwfwrc-a(1/99)-1/2 http://www.unidocs.org Rev.02/16/00 <br />