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/a a o NIFIED PROGRAM CONSOLIDATED FOPR#: U O/(),5 vS 33 ?FAC#: UNDERGROUND STORAGE TANKS - Yd'2j/3 1 6LI ,e-c,,^ (one page per site) TYPE OF ACTION ❑ 1 NEW SITE PERMIT ❑ 3.RENEWAL PERMIT ❑ S.CHANGE OF INFORMATION ❑ 7.PERMANENTLY CLOSED SITE (Check one item only) ❑ 4.AMENDED PERMIT / 8.TANK REMOVED ❑6.TEMPORARY SITE CLOSURE ` 400 I.FACILITY/SITE INFORMATION 3- BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 FACILITY ID# PR ID# y NEAREST CROSS STREET c;21001 k). 401 FACILITY OWNER TYPE ❑4.LOCAL AGENCY/DISTRICT* ❑ 1.CORPORATION ❑ 5.COUNTY AGENCY' BUSINESSEl I GAS STATION FARM ❑ 5.COMMERCIAL E] 2.INDIVIDUAL ❑ 6.STATE AGENCY* ❑ TYPE ❑ 3.PARTNERSHIP 2.DISTRIBUTOR 4.PROCESSOR E] 6.OTHER 403 7.FEDERAL AGENCY 402 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 operates REMAINING AT SITE trustlands? the UST(This is the contact person for the tank records.) v404 ❑ Yes ❑ No 405 406 II.PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407 PHONE 40's MAILING OR STREET ADDRESS auv CITY 410 1 STATE 411 ZIP CODE 412 PROPERTY OWNER TYPE ❑ I.CORPORATION ❑ 2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY ❑3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY 413 III.TANK OWNER INFORMATION TANK OWNER NAME 414 PHONE 41; MAILING OR STREET ADDRESS 416 CITY 417 1 STATE 411 1 ZIP CODE 411) TANK OWNER TYPE ❑ 1.CORPORATION ❑ 2.INDIVIDUAL ❑ 4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY 42" ❑ 3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY(TK)HQ 44- 1 Call(916)322-9669 if questions arise 421 V.PETROLEUM UST FINANCIAL RESPONSIBILITY INDICATE METHOD(s) ❑ 1.SELF-INSURED ❑4.SURETY BOND ❑ 7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM ❑2.GUARANTEE 1:15.LETTER OF CREDIT ❑ 8.STATE FUND&CFO LETTER ❑99.OTHER ❑3.INSURANCE ❑6.EXEMPTION ❑ 9.STATE FUND&CD 422 VI.LEGAL NOTIFICATION AND MAILING ADDRESS Check one box to indicate which address should be used for legal notifications and mailing. ❑ 1.FACILITY ❑2.PROPERTY OWNER ❑3.TANK OWNER 423 Legal notifications and mailing will be sent to the tank owner unless box I or 2 is checked. VII.APPLICANT SIGNATURE Certification-I certify that the information provided herein is we and accurate to the best of my knowledge. SIGNATURE OF APPLICANT DATE 424 1 PHONE 425 NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 427 STATE UST FACILITY NUMBER(For kw ue only) 428 1998 UPGRADE CERTIFICATE NUMBER(For loos use only) 429 Is 1998 Compliant? UPCF(1/99 revised)