BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

UNIFIED PROGRAM CONSOLIDATED FORM g'^I TANKS 1'�1 UNDERGROUND STORAGE TANKS - FACILITY f (one page per site) Page_Of- ` W` TYPE OF ACTION ❑ 1.NEW SITE PERMIT ❑3.RENEWAL PERMIT IR5.CHANGE OF INFORMATION ❑ 7.PERMANENILY CLOSED SITE (Check one item only) D 4.AMENDED PERMIT specify change local use only ❑ 8.TANK REMOVED ❑6XEMPORARY SITE CLOSURE coo A,n� I. FACILITY/SITE INFORMATION BUSINESS NAME(S.as FACILITY NAME or DBA-Ddng Bmirien As) 2 FACILITY IDk O O D r NEA C O SST -7 tot FACILITY OWNER TYPE U 4.LOCAL AGENCY/DISTRICT' t OT ❑ 1.CORPORATION ❑5.COUNTY AGENCY- BUSINESS 19 I.GAS STATION U 3.FARM U 5. COMMERCIAL 2.INDIVIDUAL ❑6.STATE AGENCY- TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR❑6. OTHER us ❑ 3.PARTNERSHIP ❑7.FEDERAL AGENCY- em. ami M,l ll uut TOTAL NUMBER OF TANKS Is facility on Indian Reservation or *If owner of UST is a public agency:name of supervisor ofdivisioha section or office which �y Il t )D / REMAINING AT SITE ,..5 ttustlandsi operates the UST(This is the contact person for the tank records.) 7/ [ �L +w ❑ Yes M No 'os rIl 406 II. PROPERTY OWNER INFORMATION ®(4rJ4STaf PROPERTY OWNER NAME/ / ,/ / 402 PHONE 4ca C� r e! u $ Iiod 91s `162 MAILING OR STREET ADDRESS h�� A eros L r CITY V t elo 1 STATE q j 411 J ZIPCODE /� 412 PROPERTY OWNER TYPE ULCORPORATION M2.TNDMDUAL U 4.LOCAL AGENCY/DISTRICT 06.STATEAGENCY ❑3.PARTNERSHIP [15.COUNTY AGENCY ❑7.FEDERAL AGENCY ahs III.TANK OWNER INFORMATION TANK OWNER NAME ale PHONE 415 MAILING OR STREET ADDRESS 416 CITY 417 1 STATE 418 1 ZIP CODE 419 TANK OWNER TYPE I.CORPORATION 2.INDIVIDUAL U 4.LOCAL AGENCY/DISTRICT EI&STATEAGENCY 420 ❑3.PARTNERSHIP ❑5.COUNTY AGENCY [17.FEDERAL AGENCY IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY TK HQ 44- 1 1 1 1 1 1 Call 916 322-9669 if questions arise 421 V.PETROLEUM UST FINANCIAL RESPONSIBILITY INDICATE METHOD(s) ❑1.SELF-INSURED [14.SURETY BOND Z 7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM [12.GUARANTEE ❑S.LEITER 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 sad mailing. �s, Legal notifications and mailings will be seat to the tank owner unless box I or 2 is checked I.FACILITY W 2. PROPERTY OWNER 3.TANK OWNER 423 VII.APPLICANT SIGNATURE Certification-1 certify dust the information provided herein is we and accurate to dse best of my krmA dge. SIGNA}.RE OF APPLICANT DATE 9A4 . -7 4bt HONE 425 NAME PLICANT(print _ - 4> TITL AP LIC 6? 4V STATE UST FACILITY NUMBER(For low ase only) egg 1998 UPGRADE CERTIFICATE NUMBER(For Lod hon wy) 429 UPCF(1/99 revised) 8 Formerly SWRCB Form A