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o <br /> jr-UMD PROGRAM CONSOLIDATED FO <br /> %`U�3 TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY °3 <br /> (one page per site) Page of <br /> TYPE OF ACTION ❑ 1.NEW SITE PERMIT ❑3.RENEWAL PERMIT ❑5.CHANGE OF INFORMATION ❑ TPERMANENTLY CLOSED SITE <br /> (Check one item orily) ❑4.AMENDED PERMIT specify change local use only ❑8.TANK REMOVED <br /> ❑&TEMPORARY SITE CLOSURE 400 <br /> L FACILITY/SITE INFORMATION <br /> BUSINESS NAW(Sarne®FACILrrYNAME o DBA-Doing Business As) 3 FACILITYID# <br /> n► �arr�� Se���� Tic- f� yDS ' <br /> NEAREST CROSS STREET [�( ,�4Cy 401 FACILITY OWNER TYPE ❑4.LOCAL AGENCYIDISTRICT* <br /> 9?CCORPORATION ❑5.COUNTY AGENCY* <br /> BUSINESS ❑1.GAS STATION ❑3.FARM . COMMERCIAL ❑ 2 INDIVIDUAL ❑6.STATE AGENCY* <br /> TYPE [12-DISTRIBUTOR ❑4.PROCESSOR[16- OTHER 403 ❑ 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 mine of supervisor of division,section or office which <br /> REMAINING AT SITE trustlands? operates the UST(This is the contact person for the tank records.) <br /> ! 404 ❑ Yes jBNo 405 406 <br /> R PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408 <br /> C � �� 400 <br /> �Q_4''f� ��t'E.t((...� _�4-trt t'.- � ✓�..t.�f <br /> MAILING OR STREET ADDRESS 409 <br /> /.-"3 80 <br /> CITY 410 1 STATE 411 ZIP CODE 412 <br /> PROPERTY OWNER TYPE R1.CORPORATION ❑2 INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY <br /> ❑3.PARTNERSHIP [15.COUNTY AGENCY ❑7.FEDERAL AGENCY 413 <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> A,ko Parte I °%- 3 73- f-100 <br /> MAILING OR STREET ADDRESS 416 <br /> 13a6) 5/)09C '00�zlVq-, <br /> CITY ) 1 417 STATE 418 ZIP CODE 419 <br /> TANK OWNER TYPE &TCORPORATTON 2 INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT E36.STATE AGENCY 420 <br /> ❑3_PARTNERSHIP ❑5_COUNTY AGENCY [17-FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY HQ 44- 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 [17 STATE FUND ❑10.LOCAL GOVT MECHANISM <br /> [:12 GUARANTEE [15.LETTER OF CREDIT [18.STATE FUND&CFO LETTER ❑ 99.OTHER-- <br /> 0 <br /> THER❑3.INSURANCE [16.EXEMPTION ❑9.STATE FUND&CD 422 <br /> VL 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 1 or 2 is checked ❑ 1.FACILITY ❑2 PROPERTY OWNER 3.TANK OWNER 423 <br /> VIL APPLICANT SIGNATURE <br /> Certification-I certify that the information provided herein is true and accurate to the best of my knowledge. <br /> DATE 424 PHO 425 <br /> SIG <br /> 07. 2- :? a 3 917. 3 <br /> NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 427 <br /> S7-vew F. cep-TFe- D117fle-7-PC T EN41NEC-y21044 #101tOJ2 <br /> STATE UST FACILITY NUMBER(For imai use only) 428 1998 UPGRADE CERTIFICATE NUMBER(Forlocal use only) 429 <br /> UPCF(1/99 revised) 8 Formerly SWRCB Form A <br /> I <br />