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VTF0 PROGRAM CONSOLTDATFD FO <br />TANKS <br />UNDERGROUND STORAGE TANKS -FACILITY <br />(one page per site) Page _ of _ <br />TYPE OF ACTION ❑ 1. NEW SITE PERMIT ❑ 3. RENEWAL PERMIT Of 5.CHANGE OF INFORMATION ❑ TPERMANENTLY 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. FACILITY / SITE INFORMATION <br />BUSINESS NAME (Sam as FACILITY or DBA -Doing Business As) 3 <br />FACILITY ID# <br />pNA�MEE <br />Ffl, A/ k.5 <br />NEAREST CROSS STREET 401 <br />FACILITY OWNER TYPE 4. LOCAL GENCY/DISTRICT* <br />A l r, P p -7- WAY <br />❑ 1. CORPORATION ❑ 5. COUNTY AGENCY* <br />2. INDIVIDUAL ❑ 6. STATE AGENCY* <br />BUSINESS 1. GAS STATION 3. FARM 5. COMMERCIAL <br />TYPE ❑ 2. DISTRIBUTOR ❑ 4. PROCESSOR ❑ 6. OTHER 4o3 <br />❑ 3. PARTNERSHIP ❑ 7. FEDERAL AGENCY* 402 <br />TOTAL NUMBER OF TANKS <br />Is facility on Indian Reservation or <br />*If owner of UST is a public agency: name of supervisor of division, section or office which <br />REMAINING AT SITE <br />trustlands? <br />operates the UST (This is the contact person for the tank records.) <br />404 <br />❑ Yes No 405 <br />406 <br />II. PROPERTY OWNER INFORMATION <br />PROPERTY OWNER NAME 407 <br />PHONE 408 <br />MAILING OR STREET ADDRESS 4W <br />CHS ato <br />N % @ C 0'_C A ® <br />STATE 41I <br />Cr <br />ZIP CODE -337 atz <br />PROPERTY OWNER TYPE ❑ 1. CORPORATION ❑ 2. INDIVIDUAL ❑ 4. LOCAL AGENCY / DISTRICT ❑ 6. STATE AGENCY <br />[13. PARTNERSHIP [15. COUNTY AGENCY ❑ 7. FEDERAL AGENCY 413 <br />III. TANK OWNER INFORMATION <br />TANK OWNER NAMEPHONE 415 <br />% <br />G4 C✓ f N® <br />MAILING OR STREET ADDRESS f` 416 <br />Y_ <br />CIT`i 417 STATE 418 . ZIP CODE d7 419 <br />IV\Ct lV% 7-2 C Cl._. C--_ �-- / . <br />I <br />TANK OWNER TYPE LJ1 1. CORPORATION El 2. INDIVIDUAL 4. LOCAL AGENCY I DISTRICT Lj 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) HQ 44- Call (916) 322-9669 if questions arise 421 <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br />INDICATE METHOD(s) ❑ 1. SELF-INSURED ❑ 4. SURETY BOND [17. STATE FUND ❑ 10. LOCAL GOVT MECHANISM <br />[12. GUARANTEE ❑ 5. LETTER OF CREDIT ❑ 8. STATE FUND & CFO LETTER ❑ 99- OTHER: <br />❑ 3. INSURANCE ❑ 6. EXEMPTION [19. 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. <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 423 <br />VII. APPLICANT SIGNATURE <br />Certification - I,certify that the information provided herein is true and accurate to the best of my knowledge. <br />SIGNATURE OF APPLICANT <br />DATE 424 <br />PHONE au <br />NAME OF APPLICANT (print) 426 <br />TITLE OF APPLICANT.. 427, <br />STATE UST FACILITY NUMBER (Forloeai use only)428 <br />1998 UPGRADE CERTIFICATE NUMBER (For !Deal use only) 429 <br />UPCF (1/99 revised) 171 Formerly SWRCB Form A <br />