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IFIE101 PROGRAM CONSOLIDATED FO _ /I�y <br /> TANKS (� 7 <br /> UNDERGROUND STORAGE TANKS - FACILITY ��� <br /> (One page per site) Page_of <br /> TYPE OF ACTION ❑I.NEW PERMIT [:13.RENEWAL PERMIT ET5.CHANGE OF INFORMATION [17.PERMANENTLY CLOSED SITE <br /> (Check one iron only) [14.AMENDED PERMIT (Specify change) ❑8.TANK REMOVED <br /> [16.TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION <br /> BUSINESS NAMES.as FACILITY NAMP.or Dan-Dons ea:me::ns) a. FACILITY <br /> R R Ro Mc. 8S it ° e <br /> NEARES ROSS STREET ao1. FACILITY OWNER TYPE ❑4.LOCAL AGENCY/DISTRICT- <br /> +�+ <br /> C Ciey 17 AS/Q. I.CORPORATION ❑5.COUNTY AGENCY• <br /> BUSINESS 5Q 1.GAS STATION Ll 3.FARM Lj 5.COMMERCIAL 403. [:12.INDIVIDUAL ❑6.STATE AGENCY* <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR ❑6.OTHER ❑3.PARTNERSHIP ❑7.FEDERAL AGENCY* <br /> TOTAL NUMBER OF TANKS +0+ Is facility on Indian Reservation 405. •If owner of UST is a public agency: name of supervisor of division,section or 406. <br /> REMAINING AT SITE or trust lands? office which operates rhe UST. (This is the contact person for the tank records.) <br /> ❑Yes RNo K {,R 1! M S I n/'G+4 <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 'as. <br /> KUL.W ND - lo - y 1134 . <br /> MAILING OR STREET ADDRESS 409. <br /> 4 I o R 0- <br /> CITY 410 STATE 411. ZIP CODE5-759. +t2. <br /> (2 TYP1. c �l 3 . <br /> ER <br /> PROPERTY OWNE CORPORATION 2.INDIVIDUAL 4.LOCAL AGENCY/DISTRICT 6.STATE AGENCY 415_ <br /> [:13 PARTNERSHIP [15.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> II1.TANK OWNER INFORMATION <br /> TANKOWNERNAME 414. PHONE 415. <br /> MAILING OR STREET ADDRESS - •416. <br /> 1 5 RD <br /> CITY u7. STATE aa. ZIP CODE 419. <br /> R c <br /> TANK OWNER TYPE I.CORPORATION 2.INDIVIDUAL Lj 4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 420. <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> W.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY TK HQ 44- 101Call 916 322-9669 if questions arise 421. <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ❑I.SELF-INSURED [14.SURETY BOND ❑7.STATE FUND [110 LOCAL GOVT MECHANISM 422 <br /> [12.GUARANTEE ❑5.LETTER OF CREDIT [18 STATE FUND&CFO LETTER [199,OTHER: <br /> [13.INSURANCE [16.EXEMPTION ❑9.STATE FUND&CD <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one box to indicate which address should be used for legal notifications and nailing. <br /> Legal notificatimu and mailings will be sent m the tank owner unless box I or 2 is checked. PC I.FACILITY ❑2. PROPERTY OWNER ❑3.TANK OWNER 423. <br /> VII.APPLICANT SIGNATURE <br /> Certification: I certify that the information provided herein is Ine and accurate to the best of my knowledge. <br /> SIGNATURE LICANT DATE +z+- PHONE ers. <br /> O l � b o -'%S4-1 :220 <br /> NAME OF APPLICANT(print) 426_ TITLE OF APPLICANT 427. <br /> v%M 1 V_ G . <br /> STATE UST FACILITY NUMBER(Agency ase only) 428. 1998 UPGRADE CERTIFICATE NUMBER(Asncy nae only) 429 <br /> (See Data Element I,above. <br /> UPCF HWfwrc-a(1/99)-Id http://www.unidoes.org Rev.02/16/00 <br />