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FIED PROGRAM CONSOLIDATED FOB TANKS 1�'�a F7 UNDERGROUND STORAGE TANKS - FACILITY �� (One page per site) Page_of TYPE OF ACTION G'I.NEW PERMIT [13.RENEWAL PERMIT ❑5.CHANGE OF INFORMATION ❑7.PERMANENTLY CLOSED SITE 400. (Check one item only) ❑4.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. 1 FACILITY W i"QA t�k4 Cqb*¢4A ID#ata) I. NEAREST CROSS STREET` 4ol. FACILITY OWNER TYPE 4.LOCAL AGENCY/DISTRICT* 402. 1.CORPORATION ❑5.COUNTY AGENCY* BUSINESS 1.GAS STATION 3.FARM 5.COMMERCIAL 403. ❑2.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.) 2 ❑Yes RrNo H. PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407. -fl-2- 3S63 Pftt hL Cc�Po�ht„af PHO toy `t�� - aog. MAILING OR STREET ADDRESS 409. CITYK?+y� 410. 1 STATE CA 411. ZIP CODE alz. PROPERTY OWNER TYPE 1.CORPORATION [:12.INDIVIDUAL El 4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 413. ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY M.TANK OWNER INFORMATION TANK OWNER NAME 414. PHONE 415. W �v RP9�ts6 we . Zoq) AWL-23+1} MAILING OR STREET ADDRESS ala, tF3� rJ •iN it S onl wA`i CITY SIuCk�Ia.l 417. STATE CA 418. ZIP CODE °IS 2aS 419. TANK OWNER TYPE 01.CORPORATION [:12.INDIVIDUAL 4.LOCAL AGENCY/DISTRICTE16.STATEAGENCY azo. ❑3.PARTNERSHIP ❑5.COUNTY AGENCY [17.FEDERAL AGENCY IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY TK HQ 44- It 4 le I b I Call 916 322-9669 if questions arise 421. V.PETROLEUM UST FINANCIAL RESPONSIBILITY INDICATE METHOD(s) [11.SELF-INSURED ❑4.SURETY BOND [17.STATE FUND ❑10.LOCAL GOV'T MECHANISM 422 ❑2.GUARANTEE ❑5.LETTER OF CREDIT �e.STATE FUND&CFO LETTER ❑99.OTHER: ❑3.INSURANCE ❑6.EXEMPTION [19.STATE FUND&CD VI.LEGAL NOTIFICATION AND MAILING 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. 01"I.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• HONE 425. 12- le dos (�) q1Z -2.3" NAME OF APPLICANT(print) 426. TITLE OF APPLICANT 427. PAI,'-- 'J tMC E Cifb is alewow STATE UST FACILITY NUMBER(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