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* F FIED PROGRAM CONSOLIDATED FO b l0 TANKS 3 UNDERGROUND STORAGE TANKS - FACILITY�/0111�a (One page per site) Page_of_ TYPE OF ACTION ❑ I.NEW PERMIT 3.RENEWAL PERMIT ❑5.CHA OF INFORMATION ❑7.PERMANENTLY CLOSED SITE 4W. (Check one item only) 4.AMENDED PERMIT (Specify change) V t�T L*00 ❑8.TANK REMOVED ❑6.TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION BUSINESS NAM E(Same as FACILITY NAME or DBA-Doing Business As) 3. FACILITY O A( A 2 a 12 rG it- 3 S I D#F4e2q1 ✓C NEAREST CROSS STREET 15 f4Ai4 401. FACILITY OWNER TYPE ❑4.LOCAL AGENCY/DISTRICT* 402. 0 L,L "b2I✓E ❑ 1.CORPORATION ❑5.COUNTY AGENCY* BUSINESS 1.GAS STATION ❑3.FARM ❑5.COMMERCIAL 403• ❑2.INDIVIDUAL ❑6.STATE AGENCY* TYPE ❑2.DISTRIBUTOR [14.PROCESSOR ❑6.OTHER [:13.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.) 3 ❑Yes 9)No IL PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407. PHONE 408. BOA FAME M Arlt ILET'S T4C - S'/0 - 3 2. - S"_)_0 0 MAILING OR STREET ADDRESS 409. Z s'-o(o k( V l v- r"(\ ST-- CITY 410. STATE 411• ZIP CODE 411►� A.( u1'r�iz� C A q ys y.� PROPERTY OWNER TYPE 1.CORPORATION 2.INDIVIDUAL 4.LOCAL AGENCY/DISTRICT C1 6.STATE AGENCY 413. ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY III.TANK OWNER INFORMATION E 415, TANK OWNER NAME 414. PHON o►, FialtE A-2.IGr� c . S MAILING OR STREET ADDRESS 416. Z so6 �f t(Cr�.l sr - CITY 417. STATE 418. ZIP CODE 419. 14 A.( u/J2o C A 9 ys zlSSS TANK OWNER TYPE 19 1.CORPORATION ❑2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 420. 3.PARTNERSHIP 5.COUNTY AGENCY 0 7.FEDERAL AGENCY IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY TK)HQ 44- 1 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 7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM 411 ❑2.GUARANTEE ❑5.LETTER OF CREDIT ❑8.STATE FUND&CFO LETTER ❑99.OTHER: ❑3.INSURANCE [16.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 trailing. 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 423. VII.APPLICANT SIGNATURE Certification: I certify that the information pro •ded herein is true and accurate to the best of my knowledge. SIGNATURE OF APPLICAIM DATE 424. PHONE 425. 6 /16 /03 - NAME OF APPLICANT(punt) 426. TITLE OF APPLICANT 427. iCOAF- E - c I nt C 014r1ZQC7-0rL_ STATE UST FACILITY NUMBER(Agency use only) 428• 1998 UPGRADE CERTIFICATE NUMBER(Agency use only) 429. (See Data Element 1,above. UPCF Hwfwrc-a(1/99)-1/2 http://www.unidoes.org Rev.02/16/00