COMPLIANCE INFO_1998-2008 - Laserfiche WebLink

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, IFIED PROGRAM CONSOLIDATED F TANKS UNDERGROUND STORAGE TANKS - FACILITY (One page per site) Page_of TYPE OF ACTION [11.NEW PERMIT ❑3.RENEWAL PERMIT ❑S.CHANGE OF INFORMATION ❑7.PERMANENTLY CLOSED SITE 400. (Check one item only) ❑4.AMENDED PERMIT (Specify change) ❑S.TANK REMOVED ❑6.TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3. 1 FACILITY IDN 1' NEAREST CKOSS STRWA, 401 FACILITY OWNER 7YPE 4.LOCAL AGENCY/DISTRICT° 402. V, V'A ❑ 1.CORPORATION ❑S.COUNTY AGENCY* BUSINESS Pki.GAS STATION El 3.FARM El 5.COMMERCIAL 403. (d2.INDIVIDUAL ❑6.STATE AGENCY* TYPE ❑2.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 XNo II. PROPERTY OWNER INFORMATION PROPERTY OWN ER NAM E7. PHONE 408 MAILING OR STREET ADDRESS Q✓W 409. 1,9101 S va- d /�� 61ab C Ste- v� Com. �, 11-0 CITY 410. STATE 411. ZIP CODE 412 �- c (-k iav� I C w el r 1_0 G PROPERTY OWNER TYPE U 1.CORPORATION IU2.INDIVIDUAL 0 4.LOCAL AGENCY/DISTRICT 06.STATEAGENCY 413, 3.PARTNERSHIP [15.COUNTY AGENCY ❑7.FEDERAL AGENCY III.TANK OWNER INFORMATION TANKOWNERNAME 414, PHONE 415. �\kQC4 .S S M LA'a.v- Zv - 9 yr- 9 Of MAILING OR STREET ADDRESS 416 CITY 417 STATE 41s. ZIP CODE 419 TANK OWNER TYPE 0 1.CORPORATION 2.INDIVIDUAL 0 4.LOCAL AGENCY/DISTRICT 6.STATE AGENCY 420 3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY TK HQ 44- 1 A i I Call 916 322-9669 if questions arise 421. V.PETROLEUM UST FINANCIAL RESPONSIBILITY INDICATE METHOD(s) ❑1.SELF-INSURED. ❑4.SURETY BOND ❑7.STATE FUND ❑10.LOCAL GOVT MECHANISM 422 1-12.GUARANTEE ❑5.LETTER OF CREDIT [IS.STATE FUND&CFO LETTER ❑99.OTHER: INSURANCE ❑6.EXEMPTION ❑9.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. ,b(LI,.FACILITY ❑2. PROPERTY OWNER ❑3.TANK OWNER 423, VII.APPLICANT SIGNATURE Cert' certif that the information provided herein is true and accurate to the best of my knowledge. SIGN PPLI NT n DATE 424, 1 PHONE 425, 2,9 NAME OF APPLICANT(print) 426. TITLE OF APPLICANT 427. M 0 VX CA tM CL CP 3-A k- 69-c-d q e k STATE UST FACILITY NUMBER(Agency use only) 428 1998 UPGRADE CERTIFICATE NUMBER(Agency use only) 429_ (See Data Element 1,above. to -a(1 1t7t 12ttpd/trrrw unldoca org .,. NMI' *.r a .r r "rr r, Zxiy se.�. S w`!�:, ,,t t ar,=- PUMP, y�,