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�YIFIED PROGRAM CONSOLIDATED FO /,.ICj U Z PR#: cJ !!nn FAC#: UNDERGROUND STORAGE TANKS -FACIQ� 6�/ 1 one page per site) TYPE OF ACTION ❑ I.NEW SITE PERMIT ❑3.RENEWAL PERMIT ❑ 5.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 s BUSINESS NAME(Same m FACILITY NAME or DBA-DoingBsiess M) 3 FACRSTY ID# PR ID# A kL zV03,7at1 0 2 2 NEAREST CROSS STREET FACILITY OWNER TYPE El� w 401 4.LOCAL AGENCY/DISTRICT- 4v\0. �'1.CORPORATION ❑ 5.COUNTY AGENCY- BUSINESS5.COMMERCIAL ❑ 2.INDIVIDUAL TYPE 1i L GAS STATION El 3.FARM ❑ 6.STATE AGENCY- TYPE DISTRMUTOR El4.PROCESSOR ❑ 6.OTHER 403 ❑ 3.PARTNERSHIP ❑ 7.FEDERAL AGENCY- 402 TOTAL NUMBER OF TANKS Is facility on Indian Reservation or •Ifowner of UST is a public agency:name ofsupervisor ofdivisim.section or office which operates REMAINING AT SITE trustlands? the UST(This is the contact person for the tank records.) 2 404 ❑ Yes XNo 405 406 II.PROPERTY OWNER INFORMATION PROPERTI:,07R NAME 402 PHONE 408 IJfSY MAILING OR STREET ADDRESS 409 CITY 410 STATE 411 ZIP CODE 412 PROPERTY OWNER TYPE ❑ 1.CORPORATION x 2.INDIVIDUAL ❑ 4.LOCAL AGENCY/DISTRICT 116.STATE AGENCY 1:13.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑7.FEDERAL AGENCY 413 III.TANK OWNER INFORMATION TANKOWNERNAME 414 PHONE 415 MARLING OR STREET ADDRESS 416 CITY 417 STATE 418 ZIP CODE 419 TANK OWNER TYPE ❑ 1.CORPORATION ❑ 2.INDIVIDUAL El 4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY 420 ❑ 3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY(TK)HQ 44- Call(916)322-9669 if questions arise 421 V.PETROLEUM UST FINANCIAL RESPONSIBILITY INDICATE METHOD(s) ❑ I.SELF-INSURED 114.SURETY BOND ❑ 7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM ❑2.GUARANTEE 115.LETTER OF CREDIT ❑ S.STATE FUND&CFO LETTER 1:199.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 maifing. ❑ 1.FACILITY ❑2.PROPERTY OWNER ❑3.TANK OWNER 423 Legal notifications and mailing will be sent to the tank owner unless box 1 or 2 is checked. VII.APPLICANT SIGNATURE Certification-I certify that the infommtion provided herein is we and accurate to the best ofmy knowledge. SIGNATURE OF APPLICANT DATE 424 PHONE 425 NAME OF APPLICANT(print) 426 TITLE OF APPLICANT Orr STATE UST FACILITY NUMBER(Fmlocal m only) 428 1998 UPGRADE CERTIFICATE NUMBER(Forlocal meonty) 429 Is 1998 Compliant? UPCF(1/99 revised)