Laserfiche WebLink
USED PROGRAM CONSOLIDATED FORAO <br /> 1 TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (One page per site Page_of <br /> TYPE OF ACTION ❑1.NEW PERMIT [13.RENEWAL PERMIT ❑5.CHANGE OF INFORMATION O B.TANK RECO Y CEASED SITE 1 <br /> ao0 <br /> (Check one item only) ❑4.AMENDED PER:MIIT (Specify change) <br /> ❑6.TEMPORARY SITE CLOSURE v <br /> I. FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Same m FACILITY NAME or DBA-Doing Business As) 3. FACILITY n n i "AGENCYIDISTRICT* <br /> i%.ri�►re Mirr� WY4- tl 1/ �1 <br /> NEAREST CROSS STREET aot. FACILITY OWNER TYPE ❑4.LOCA1.CORPORATION ❑5.COUN <br /> BUSINESS DQ 1.GAS STATION ❑3.FARM ❑5.COMMERCIAL 403. 2.INDIVIDUAL ❑6.STATE AGENCY= <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR [16.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 J�j No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407• PHONE 408. <br /> �7Nt NPrI?aT� �� kAA55Fkt-J FAWA Citi) -8 160 <br /> 4°9. <br /> MAILING OR STREET ADDRESS <br /> 33ou- Ind irlAfm m eP, L1J�A <br /> CITY 410 STATE Ott. ZIP CODE 41z. <br /> $'to&k j-O" Ft Ci 5 2-1 <br /> PROPERTY OWNER TYPE ❑ 1.CORPORATION ®2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT Ll 6.STATE AGENCY ata. <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL.AGENCY <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. 1 PHONE 415. <br /> SN 1 HPfP,Qe'F" p <br /> 416. <br /> MAILING OR STREET ADDRESS i' 1 g <br /> 4 i W3 j j 11J �-t <br /> CITY 417. STATE a18. ZIP CODE 419 <br /> *YCC_1=-row C& 95 207 <br /> TANK OWNER TYPE ❑ 1.CORPORATION 7.INDIVIDUAL [14.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 420. <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL.AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY TK)H 44- 1 1Call 916 322-9669 if questions arise 421. <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) [11.SELF-INSURED [14.SURETY BOND ❑7.STATE FUND ❑10.LOCAL GOVT!ECHANISM 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. 423 <br /> Legal notifications and mailings will be sent to the tank owner unless box 1 or 2 is checked. 1.FACILITY [12. PROPERTY OWNER ❑3_TANK OWNER <br /> VII.APPLICANT SIGNATURE <br /> Certification: I certify that the information provided herein is true and acc=te to the best of my knowledge. <br /> PLI� DATE 424. PHONE azs. <br /> E� <br /> S[ R <br /> -" ANT �Il <br /> 2 s, <br /> 426. TITLE OF APPLICANT <br /> N OF APPLICANT(print) 427. <br /> SNI"09ar J � � tFt �W�NEtZ <br /> STATE UST FACILITY NUMBER(Agency use only) <br /> 428. 1998 UPGRADE CERTIFICATE NUMBER(Ag..y�e mIy) 429. <br /> (See Data Element 1,above. <br /> UPCF Hwfwrc-a(1/99)-1/2 http://www.unidoes.org Rev.02/16/00 <br />