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FLED PROGRAM CONSOLIDATED FO <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (One page per site) Page_of <br /> TYPE OF ACTION ❑1.NEW PERMIT ❑3.RENEWAL PERMIT [15.CHANGE OF INFORMATION [17.PERMANENTLY CLOSED SITE 400-11 <br /> (Check one item only) ❑4.AMENDED PERMIT (Specify change) ❑8.TANK REMOVED <br /> ❑6.TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Sana:as FACILITY <br /> pN�AME or DBA-Doing Busies As) 3. FACILITY F n ® 3 �g 9tt <br /> inC1111n e M 11'11 tv Ih 1r}- ID# t1 / V <br /> I F <br /> NEAREST CROSS STREET 401. FACILITY OWNER TYPE 4.LOCAL AGENCY/DISTRICT' 4. <br /> q ®1 <br /> 1-.5 ❑1.CORPORATION ❑5.COUNTY AGENCY' \ <br /> BUSINESS 1.GAS STATION 3.FARM 5.COMMERCIAL 403: 142.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 tate tank records.) <br /> 4 ❑Yes �A No <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408. <br /> "A55At-J $AWA 20rj- q51 -8160 <br /> MAILING OR STREET ADDRESS 409. <br /> 33ot� W "Arun"FP, L AOZ-1 <br /> Com, 410. STATE 411. 1 ZIP CODE 412. <br /> $ToLkcoty c A G15219 <br /> PROPERTY OWNER TYPE 1.CORPORATION 912.INDIVIDUAL 4.LOCAL AGENCY/DISTRICT Li 6.STATE AGENCY 413. <br /> [13.PARTNERSHIP [15.COUNTY AGENCY ❑7.FEDERAL,AGENCY <br /> III.TANK OWNER INFORMATION <br /> TANKOWNERNAME 414. 1 PHONE 415. <br /> 2- 0- 11- <br /> ��I- 2L13 - 4u55 <br /> MAILING OR STREET ADDRESS 416. <br /> CITY 417. STATE 418. ZIP CODE 419. <br /> SYS-k-rot� C& 95 2- 7 <br /> TANK OWNER TYPE 1.CORPORATION 2.INDIVIDU El 4.LOCAL AGENCY/DISTRICT 06.STATEAGENCY 420. <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY [17.FEDEIL$L AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TPH9 44- 1 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 ❑lo.LOCAL GOVT MECHANISM 422 <br /> ❑2.GUARANTEE ❑5.LETTER OF CREDIT ❑S.STATE FUND&CFO LETTER ❑99.OTHER: <br /> [13.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. W 1.FACILITY [12. PROPERTY OWNER ❑3.TANK OWNER 423. <br /> VII.APPLICANT SIGNATURE <br /> Certification: I certify that the information provided herein is true and accurate to the best of my knowledge. <br /> SI RE PL ANT DATE 424. PHONE 425. <br /> �S 2s, _ r 2(1-7_qB-Q-0S9 <br /> N OF APPLICANT(print) 426. TITLE OF APPLICANT 427. <br /> SNS M-P War J t ASS 9 A OW FNCrL <br /> STATE UST FACILITY NUMBER(Agency use only) 428- 1998 UPGRADE CERTIFICATE NUMBER(Agency ase 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 />