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Dec 11 03 07: 25a R t= BRLRJI 151 25924 p. 2 <br /> IUNWIED PROGRAM CONSOLIDATED FORM PR#:PR0504388 <br /> WAC O:FAM618 <br /> UNDERGROUND STORAGE TANKS-FACILITY <br /> foot pas�per site) <br /> TYPE OF ACTION NEW U7E PERMIT ❑3.RENEWAL PERMIT © 5,CHANGE OF INFORMATION Q 1.PERMANENTLY CLOSED SITE <br /> (C'b.ck aAt ilcm 0ab4 ❑d.AMENDED PERMIT <br /> Q 6.TANK tt6NaOVF.D <br /> ®a.TEMPORARY SITE CL0.5URF +oo <br /> I,.FACILITY I SITE INFORMATION 1 W S FL DORADO ST,STOCIETOti C-A Ct -X <br /> BUSINONAMEtSmnen,FAMIT NAMaORA-nofaSawa.sA: I FACIIITYID,y RIDri <br /> HIP A.MAR ENTERPRISES FA000619; p1tn5043Ra ' <br /> NEAREST CROSS STRE•EI FACILITY Y U NER TYPE <br /> WI []?.LOCAL TIG&NC1'!D]STRT(T• <br /> EL DORADO ❑ i. RATION s.cotllYTYAGENCY" <br /> BUSW S r.rjaS STATION ❑s FARM (�S.COMMEFCIAL I.1MDI-.AL <br /> TYPE <br /> ❑ ❑b.STATE AGENCY' <br /> [B.2.Dt5TRUT6R ( a,PRaESSOR ❑4.07IIER aw ❑I.PARTNFS.SIUP �]7,FWERALACENCY" aaz <br /> TOTAL NUMBER OF T $ Is facility at Indian Reservation or rl'Po sncr ofl sT i6 n nabbe <br /> RfiMAINING AT SITE lrwstlanQs° wrcy!none oenfa.pgar of divi;on.sudor,or o>ffcewbich operatea <br /> the UST(Tlda is to eoauet ptmo for the unk records.) <br /> -°a ❑Yes ®No "A B.Al.A_TI AW.P-E - <br /> _.A:A;6,�3~ •D� <br /> 11,PROPERTY OWNER INFORMATION <br /> PROPERTY OWNEIt NAME <br /> aot ONE ap6 <br /> fs A L•R + GTsag 939-1906 <br /> MA(UNGORSTRYEZ DRE ADj1'){R�.m NTog- { 5 --r .� <br /> cclG'CA AdA D TATTV'1E <br /> CITY 3 5 •co v DV etc STATE s11 ID'CODE a12 <br /> 6 .C m® N CA 95 58+ Ct S- -� <br /> PROP£ YO TYPE 0 1 COMRATION INDIVIDUAL ®3.SACAL AGENCY/DISTRICT ❑6.STATE AGENCY <br /> Q 3.PARTNERSHIP 0 5.COUNTY AGENCY ❑7.FEDERAL AGENCY au <br /> III.TANK OWNER INFORMATION <br /> 1 <br /> TANK OWNER N.LiMew PHO""1; L0-�g M R A m 209 939-1906 eta <br /> MARANGORSTREET ADDRESS t-pV I C Ca N 0\! AA/ .la <br /> CITY <br /> •�-- ai7 AT- •tsL (:UD <br /> �1P <br /> aueemvF 1- iQ�:Y�p n}i CA %its—of 4-S-3,� <br /> TANK OWNER TYPE 191.CORPORATION -.INDIVIDUAL Q4.LOCAL AGENCY/DISTRICT 6.STATE AGENCY aro <br /> ❑3.PARTNERSHIP D S.COUNTY AGENCY ❑7.FEDERAL AG NCY <br /> 44-- rv.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> Call(916)322-9669 ifquestions at-ise .21 <br /> Y. <br /> PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE 1,1ETHOD(s) C3 I-SELF•1NSIMD 0 4.SURETY BOND 7.STATEPtT..'D 0 10.LOCAL GOVT MECHANISM <br /> ❑2.GUARANTEE 115.LETTER OF CRL•D1T 178.STATE FUND&CPO LETTER 0 99 OTHER <br /> ❑3.INSURANCE' LJ 6.EXEWTION ® 9.STATE FUND&CD 422 <br /> VP.LEGAL NOTIFICATION AND MAILING ADI)RF,SS <br /> Cheek one box ro indicate whieh 2dd,es A uld be-ed liw k--0,ot;s;e:�io,.s aau,neitiax. ® 1.FACILITY .PROPERTY OWNER ❑a.TANK O WNER azl <br /> Lega1-6iiadom aad ma111nC"[be tent to Ike unk owarr ual—bac 1 w2 is checked. <br /> VII.APPLICANT SIGNATURE <br /> Cwi9cslion•1 ccni&dm lhe,n Q .Ided Aerei.i,m,e asd acc.nte t.!h.be t af.y r,owlntigc, <br /> SIGNATME OF APPLICANT DATE s a PNONE Tit <br /> f ► 02 ;1d 6�� �4 bt <br /> NAME oPp�PL1CANT .'n A l' _ .ID TITLE OP A LICA, t `Y- <br /> STATE•U57 FACILITY NUMBER tv.ta,r. y1 �e 1998 UPGRADE CERTIFICATE NUMBER tparkeilwe caly) 42i <br /> Is 1998 Compliant?Y <br /> UPCF(L99 revised) <br /> Z9 3SVcf "-IJ HIAI-A CCOE139b6©Z 1•Z:9T E00Z/9T/7T <br />