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f <br /> ,xPB PROGRAM CONSOLIDATED FORWft <br /> TANKS <br /> ` UNDERGROUND STORAGE TA - FACILITY <br /> (one page per site) Page_of <br /> TYPE OF ACTION ❑ I.NEW SITE PERMIT ❑3.RENEWAL PERMIT ❑S.CHANGE OF INFORMATION ❑ 7.PERMANENTLY CLOSED SITE <br /> (Check one item only) ❑4.AMENDED PERMIT specify change local use only ❑ 8.TANK REMOVED <br /> ❑6.TEMPORARY SITE CLOSURE 400 <br /> I. FA /SITE INFORMATION <br /> BUS S NAME(same as FACn Mf NANO or DBA-noise Busisesa As) 3 FACILITY ID# -F <br /> (n ' 1 <br /> NEAREST CROSS STREET 401 FACILITY OWNER TYPE ❑4.LOCAL AGENCY/DISTRICT* <br /> 1.CORPORATION ❑5.COUNTY AGENCY" <br /> BUSINESS 1 GAS TION 3.FARM ❑5. COMMERCIAL E] 2.INDIVIDUAL ❑6.STATE AGENCY* <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR p 6. OTHER 4o3 ❑ 3.PARTNERSHIP ❑7.FEDERAL AGENCY* 402 <br /> TOTAL NUMBER OF TANKS Is facility on Indian Reservation or 'If owner of UST is a public agency:name of supervisor of division,section or office which <br /> REMAINING AT SIT trustlands? operates the UST(Chis is the contact person for the tank records.) <br /> ® 404 E] Yes No ws 406 <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME PHONE 40s <br /> , ' e Lz �I 1 <br /> MAILING OR STREET ADDRUSS 409 <br /> MOir <br /> CITY 410 STATE 411 ZIP CODE 412 <br /> et` a ,� <br /> JV j <br /> PROPERTY OWNER TYPE ❑ 1.CORPORATION 2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY <br /> ® ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY 413 <br /> III.TANK OWNER INFORMATION <br /> TANKERNAME p� 414 PONE ®S�y 415 <br /> /r /073200 <br /> 416 <br /> MAILING OR STREET ADDRESS <br /> r- C,q / <br /> ' CITY417 STATE 418 ZIP CODE 419 <br /> t VOwd I <br /> J <br /> TANK OWNER TYPE LA I.CORPORATION ❑2. UAL 4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 420 <br /> [711PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 444_ 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 ❑10.LOCAL GOVT MECHANISM <br /> ❑2.GUARANTEE ❑5.LETTER OF CREDIT ag 8.STATE FUND&CFO LETTER ❑ 99.OTHER: ..... <br /> ❑3.INSURANCE 0 6.EXEMPTION ❑9.STATE FUND&CD 422 <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one box to indicate which address should be used for legal notifications and mailing. 423 <br /> Legal notifications and mailings will be sent to the tank owner unless box I or 2 is checked. ❑ 1.FACILITY ❑2. PROPERTY OWNER 3.TANK OWNER <br /> VII. APPLICANT SIGNATURE <br /> IN <br /> Certification-I certify that the information provid oeuthe best of my knowledge. <br /> SIGNATURE OF APPLICANT DATE 424 PONE a2s <br /> f 0 %0�7 3 X&'- <br /> NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 427 <br /> STATE UST FACILITY NUMBER(For local use only) 428 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 <br /> UPCF(1/99 revised) 8 Formerly SWRCB Form A <br />