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IED PR gRAM CONSOLIDATED FO TANKS �U UNDERGROUND STORAGE TANKS - FACILITY ' (One page per site) Page_of TYPE OF ACTION ❑L NEW PERMIT ❑3.RENEWAL PERMIT 195.CHANGE OF INFORMATION ❑7.PERMANENTLY CLOSED SITE 400. (Check one item only) [14.AMENDED PERMIT (Specify change) ❑8.TANK REMOVED ❑6.TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3. FACILITY "' 1 A 1'- ID# NEAREST CROSS ST ET 401, FACILITY OWNER TYPE ❑4.LOCAL AGENCY/DISTRICT* 40z. 6-12^T ❑ 1.CORPORATION ❑5.COUNTY AGENCY* BUSINESS CK I.GAS STATION ❑3.FARM ❑5.COMMERCIAL 403. W2.INDIVIDUAL ❑6.STATE AGENCY* TYPE [:12.DISTRIBUTOR ❑4.PROCESSOR [:16.OTHER ❑3.PARTNERSHIP ❑7.FEDERAL AGENCY* 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. REMAINING AT SITE or trust lands? office which operates the UST. (This is the contact person for the tank records.) ❑Yes allo H. PROPERTY OWNER iNFORMA'ON PROPERTY OWNER NAME 407. PHONE 408. MAILING OR STREET ADDUf ADDS 409. CITY 41°. STATE 411. ZIP CODE 412. Ml n7 � C•44- t--3 PROPERTY OWNER TYPE ALCORPORATION ❑2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 413. ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY IA"TA`lYKiO NER INFORMATION TANK OWNER NAME 414. PHONE 415. MAILING OR STREET ADDRESS 416. CITY 417. STATE 418. 1 ZIP CODE 419. C44- r-36 ( TANK OWNER TYPE ❑ 1.CORPORATION X INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 420. ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY N. 30AI ()F E�VAI:IZATION=UST STORAGE FEE ACCOUNT NUMBER �. .� TY(TK)HQ 44- 0 1 Call(916)322-9669 if questions arise 421. V1.PETRQLEUM USTjANCIAL RESPONSIBILITY I FIN INDICATE METHOD(s) I&JSELF-INSURED ❑4.SURETY BOND ❑7.STATE FUND ❑10.LOCAL GOVT MECHANISM 422 U2.GUARANTEE ❑5.LETTER OF CREDIT 8.STATE FUND&CFO LETTER ❑99.OTHER: ❑3.INSURANCE ❑6.EXEMPTION ❑9.STATE FUND&CD VI.LEGAL NOTIFICATION AND MAIELING`ADDRESS Check one box to indicate which address should be used for legal notifications and mailing. Legal notifications and mailings will be sent to the tank owner unless box 1 or 2 is checked. ❑ 1.FACILITY ❑2. PROPERTY OWNER 3.TANK OWNER 423. VII.APPLICANT SIGNATURE Certification: I certify that the information provided herein is true and accurate to the best of my knowledge. SIGNATURE OF APPLICANT DATE 424, PHONE 425. NAME OF APPLICANT(print) TITLE OF AP,PnLICANT 42z STATE UST FACILITY NUKIBER(Agency use only) 428. 1998 UPGRADE CERTIFICATE NUMBER(Agency use only) 429. (See Data Element 1,above. UPCF Hwfwrc-a(1/99)-1/2 http://www.unidocs.org Rev.02/16/00