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WIFIED PROGRAM CONSOLIDATED FW ` TANKS UNDERGROUND STORAGE TANKS - FACILITY (One page per site) Page_of TYPE OF ACTION ❑1.NEW PERMIT 3.RENEWAL PERMIT ❑5.CHAj�1GE OF INFORMATION ❑7.PERMANENTLY CLOSED SITE 400 ± (Check one item only) 4.AMENDED PERMIT (Specify change) �I�01 1{%1 C h,1-14" ❑8.TANK REMOVED ❑6.TEMPORARY SITE CLOSURE I I. FACILITY/SITE INFORMATION BUSINESS NAME(Same w FACILITY NAME or DBA-Doing Business As) 3. FACILITY GLu I V_ Sro P +k 3 9 ID# '. �;F 40). FACILITY OWNER TYPE ^" 4.LOCAL AGENCY/DISTRICT* 402. .2A 8S 6` �� Sf` R9 1.CORPORATION ❑5.COUNTY AGENCY* BUSINESS D9 1.GAS STATION ❑3.FARM ❑5.COMMERCIAL 403. ❑2.INDIVIDUAL ❑6.STATE AGENCY* TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR ❑6.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.) 7j ❑Yes g No II. PROPERTY OWNER INFORMATION PROPERTY OWNER NAME ONE 408. V ( LL 01.( C011'"04,4194 �rt f MAILING OR STREET ADDRESS 409 .O. B0Y, 1 Z66 CITY 410• STATE 411• 1 ZIP CODE 412 I-4uTcuireso-( V_ S G PROPERTY OWNER TYPE jg 1.CORPORATION El 2.INDIVIDUAL Lj 4.LOCAL AGENCY/DISTRICT 6.STATE AGENCY 413. ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY III.TANK OWNER INFORMATION TANK OWNER NAME ala. PHONE 415, 1QJt Sro1G&T5 MAILING OR STREET ADDRESS 416 CITY 417. STATE 418. ZIP CODE 419. 1L E.K'-0++.T- C A q �!S-3 �- TANK OWNER TYPE 1.CORPORATION ❑2.INDIVIDUAL [14.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 1 1 1 1 1 Call 916 322-9669 if questions arise 421. V.PETROLEUM UST FINANCIAL RESPONSIBILITY INDICATE METHOD(s) [11.SELF-INSURED ❑4.SURETY BOND I 97.STATE FUND [:110.LOCAL GOVT MECHANISM 422 [12.GUARANTEE ❑5.LETTER OF CREDIT ❑8.STATE FUND&CFO LETTER ❑99.OTHER: ❑3.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 I or 2 is checked. ❑ 1.FACILITY [12. PROPERTY OWNER t63.TANK OWNER 423. VII.APPLICANT SIGNATURE Certification: 1 certify that the information provided herein is true and accurate to the best of my knowledge. SIGNATURE OF APPLICANT DATE 4za. PHONE 425. '-/s- 03 16z NAME OF APPLICANT(print) 426. TITLE OF APPLICANT 427. I C N ASE L. E _ A (,"1 o r.( C 0 K r X A-,(T"'o rL_ STATE UST FACILITY NUMBER(Agency use only) 428• 1998 UPGRADE CERTIFICATE NUMBER(Agency use only) 429. (See Data Element I,above. UPCF Hwfwrc-a(1/99)-1/2 http://www.unidocs.org Rev.02/16/00 - is