COMPLIANCE INFO_1998-2008 - Laserfiche WebLink

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EINESU ED PROGRAM CONSOLIDATED FO TANKS UNDERGROUND STORAGE TANKS - FACILITY (One page per site) Page_of ❑1.NEW PERMIT ❑3.RENEWAL PERMIT ❑5.CHANGE OF INFORMATION ❑7.PERMANENTLY CLOSED SITE 400_ ❑4.AMENDED PERMIT (Specify change) ❑8.TANK REMOVED 6.TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION (Same as FACILITY NAME or DBA-Doing Business As) 3. FACILITY ID# f 1A V 1S S'rREE'l. 401 FACILITY OWNER TYPE 4.LOCAL AGENCY/DISTRICT* 402. ❑1.CORPORATION ❑5.COUNTY AGENCY* BUSINESS PkI.GAS STATION 3.FARM ❑5.COMMERCIAL 403. (Y2.INDIVIDUAL ❑6.STATE AGENCY* TYPE ❑2.DISTRIBUTOR [14.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 (�No II. PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407 PHONE ao8 MAILING OR STREET ADDRESS 9✓INE 409. CITY 410. STATE 411. ZIP CODE 412. C P'N c'i Lei 6 PROPERTY OWNER TYPE ❑ 1.CORPORATION 2.INDIVIDUAL [14.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 413. 3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY III.TANK OWNER INFORMATION TANK OWNER NAME 414. PHONE 415 416 MAILING OR STREET ADDRESS CITY 417. STATE 418. ZIP CODE 40 TANK OWNER TYPE ❑ 1.CORPORATIONT2. NDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 420 PARTNERSHIP [15.COUNTY AGENCY ❑7.FEDERAL AGENCY IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY(TK)HQ 44- 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 [110.LOCAL GOVT MECHANISM 422 2.GUARANTEE ❑5.LETTER OF CREDIT ❑8.STATE FUND&CFO LETTER C199.OTHER: .INSURANCE ❑6.EXEMPTION ❑9.STATE FUND&CD 91-4 VI.LEGAL NOTIFICATION AND MAILING ADDRESS Check one box to indicate which address should be used for legal notifications and mailing. g Legal notifications and mailings will be sent to the tank owner unless box I or 2 is checked. �Ll I.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 PPLIC NT DATE 424. 1 PHONE 425, NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 427. M o Ino(Un CL CP rN1 L-t-r C9-ev �j e k STATE UST FACILITY NUMBER(Agency use only) 428. 1998 UPGRADE CERTIFICATE NUMBER(Agency use only) 429. (See Data Element 1,above. UPCF Hwrwrc-a(1/99)-1/2 http://www.unidocs.org Rev.02/16/00