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L ED PROGRAM CONSOLIDATED FO <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILIoTYge per site) Page-of_ <br /> TYPE OF ACTION ❑1.NEW PERMIT ❑3.RENEWAL PERMIT S.CHANGE OF INFORMATION ❑7.PERMANENTLY CLOSED SITE 400. <br /> (Check one item only) <br /> ❑4.AMENDED PERMIT (Specify change) ❑9.TANK REMOVED <br /> ❑6.TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3. FACILITY O D D 1 <br /> ID# <br /> 771TI 4U2. <br /> � � Wvl <br /> NEAREST CROSS STREET 401. FACILITY OWNER TYPE ❑4.LOCAL AGENCY/DISTRICT' <br /> ❑1.CORPORATION ❑5.COUNTY AGENCY' <br /> 1l <br /> BUSINESS 1.GAS STATION 3.FARM 5.COMMERCIAL 403. (dl INDIVIDUAL ❑6.STATE AGENCY' <br /> PARTNERSHIP <br /> ❑7.FEDERAL AGENCY' <br /> ❑ ❑ 3 PARTNERSHIP(ypE ❑2.DISTRIBUTOR 4.PROCESSOR 6.OTHER 405. *❑If owner of UST is a public agency:name of supervisor of division,section or 406. <br /> TOTAL NUMBER OF TANKS 404. Is facility on Indian Reservation <br /> office which operates the UST. (This is the contact person for the tank records.) <br /> REMAINING AT SITE or trust lands? <br /> 2 ❑Yes O(No <br /> II. PROPERTY OWNER INFORMATION <br /> A ,1 t 407. PlHiONE 409. <br /> PRO\ 'o TY O CLMA4L_j S w\dam'Zig 7CWNER NAME J - cro q <br /> 409. <br /> MAILING OR STREET ADDRESS C^/�r <br /> VL�O Z °r� 1Lo <br /> 410. t�4. <br /> E 411. ZIP CODE 412. <br /> CITY (� ^ G <br /> C � 413. <br /> PROPERTY OWNER TYPE ❑ 1.CORPORATION 2.INDIVIDUAL LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY <br /> 3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> III.TANK OWNER INFORMATION <br /> 414. 1 PHONE als. <br /> � <br /> TANK OWNER NAME n QVF- 1 <br /> \ko 'X S M 1 �v- 7 4W <br /> MAILING OR STREET ADDRESS <br /> �!►r Q 419. <br /> CITY a17. STATE a19. ZIP CODE <br /> TANK OWNER TYPE ❑ I.CORPORATION 2.INDIVIDUAL a4.LOCAL AGENCY/DISTRICT Ll 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- <br /> Call 916 322-9669 if questions arise 4117 <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ❑I.SELF-INSURED ❑4.SURETY BOND ❑7.STATE FUND ❑10.LOCAL GOVT MECHANISM 41 <br /> `P.2.GUARANTEE []5.LETTER OF 3.INSURANCE ❑6.EXEMPTION <br /> LETTER ❑99.OTHER: <br /> T ON ❑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. 413, <br /> Legal notifications and mailings will be sent to the tank owner unless box 1 or 2 is checked. gt.FACILITY [12. PROPERTY OWNER [13.TANK OWNER <br /> VII.APPLICANT SIGNATURE <br /> 4ceg- certi that the information provided herein is true and accurate to the best of my knowledge. q1q. PHONE a25. <br /> PLI NT DATE <br /> 426. TITLE OF APPLICANT 427. <br /> NAME OF APPLICANT(print) <br /> "p In A VK Cr,CX 11- a (I <br /> STATE UST FACILITY NUMBER(Agency use only) <br /> 429. 1998 UPGRADE CERTIFICATE NUMBER(Agency use only) 429. <br /> (See Data Element 1,above. <br /> UPCF Hwfwrc-a(1/99)-1/2 <br /> http://www.unidocs.org Rev.02/16/00 <br />