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1A IJ116V <br /> UNl>�D PROGRAM CONSOLIDATED FORM v 4q, <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> I'��° <br /> ( Pagg of <br /> TYPE OF ACTIONL.NEW PERMIT [13.RENEWAL PERMIT [I5.CHANGE OF INFORMATION ❑7.PERMAA'EN'CLY CLOSED <br /> (Check one item only) I r D YTx-/ ❑4.AMENDED PERMIT (Specify change) ❑S.TAlQ12'Rfi. 'TG200Y,r <br /> ❑6.TEMPORARY SITE CLOSURE `�L)' 11 f- <br /> I. FACILITY/SITE INFORMATION P ENT HEALTH <br /> lip <br /> BYINESS NAMES.as FACH17 NASM or DBA-Wing Bmmers An 3. FACILITY 3 1 <br /> 1�/56y6 <br /> SSS NEAREST C$$ ao1. FACILITY OWNER TYPE 4.LOCAL AGENCY/DISTRICT" 492 <br /> L C C11.CORPORATION [15.COUNTY AGENCY" <br /> BUSINESS W1.GAS STATION Lj J.FARM 5.COMMERCIAL 403. INDIVIDUAL E36.STATE AGENCY' <br /> TYPE 2.DISTRIBUTOR ❑4.PROCESSOR ❑6.OTHER 3.PARTNERSHIP ❑7.FEDERAL AGENCY" <br /> TOTAL NUMBER OF TANKS �- Is facility on Indian Reseryation 4os. •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 the UST. (This is the contact person for the tank records.) <br /> ❑Yes �o <br /> H. PROPERTY OWNER INFORMATION <br /> PRT/O�PER7OWNERNAf•ME 40r' PHONE nos. <br /> S \ <br /> MAIL409, <br /> JNTREET A <br /> 1DDI).ESS �1 <br /> C I lu,J--IV'h'_v,'• '..'G_.ITY alo. 1 STAT E an. ZIP COD I C etz. <br /> 0 <br /> PROPERTY OWNER TYPE Li I.CORPORATION .INDIVIDUAL Ll 4.LOCAL AGENCY/DISTRICT U&STATEAGENCY 413. <br /> [13.PARTNERSHIP ❑5.COUNTY AGENCY [17.FEDERAL AGENCY <br /> M.TANK OWNER INFORMATION <br /> TANK OWNER NAME 1 414. PHONE 415. <br /> 616. <br /> MAIJ4NGOR STREET ADDRESS <br /> GI a <br /> Clre 417, 1 STATE419. ZIP CODE 419. <br /> ack <br /> TANK OWNER TYPE I.CORPORATION 2.INDIVIDUAL 4,LOCAL AGENCY/DISTRICT 6.STATE AGENCY 420. <br /> • ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY TK HQ 44- 1 1 1 1 1 1 1 Call 916 322-9669 if questions arise 421. <br /> V.PETROLEUM UST FINANCIAL RESPONSD ILrry <br /> INDICATE METHOD(s) ❑ ELFINSUREDE3ETY 4.SURBOND ❑7.STATE FUND ❑10.LOCAL GOVT MECHANISM 4u <br /> 2 GUARANTEE ❑5.LETTER OF CREDIT ❑S.STATE FUND&CFO LETTER ❑99.OTHER <br /> ❑3.INSURANCE ❑6.EXEMPTION ❑9.SPATE FUND&CD <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one box to indicate which address should be used for legal notifications and mailing. <br /> Legal ratifications and mailings will be sent to the tank owner unless box 1 or 2 is checked. El L FACILITY [12. PROPERTY OWNER [13.TANK OWNER 4n <br /> VII.APPLICANT SIGNATURE <br /> Certification: I certify,that the information provided herein is roue and accurate to the best of my knowledge. <br /> SIGMA OF APPLICAN D4 ` 4z4. g Oq "n 4zs. <br /> N /AMW�El OF APPLICANT(gnjrt),, 4 TITLE OF APPLICANT <br /> l 4z7 <br /> LAI <br /> STATE UST FACILITY NUMBER(A$e ..'only) 423. 1998 UPGRADE CERTIFICATE NUMBER(Att s are arty) 429_ <br /> (See Data Elernent 1,above. <br /> UPCF Hwfwrc-a(1/99)-112 http://www.unidOCLorg Rev.02116/00 <br />