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U 1 IED PROGRAM CONSOLIDATED'r <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY q <br /> (one gag per / <br /> Pape _ of _ <br /> TYPE OF ACTION }�\NEW SITE PERMIT r 3.RENEWAL PERMIT r 5.CHANGE OF INFORMATION(Spedfy Change- F 7.PERMANENTLY CLOSED SITE <br /> (Check one item only) (fir r' 4.AMENDED PERMIT ow,utl,only) r 8.TANK REMOVED 400 <br /> F 6.TEMPORARY SITE CLOSURE <br /> D 1 V Gj 8 �(�� '���a 3� 31.FACILITY I SITE INFORMATION <br /> BUSINESS NAME(Same ac FACILITY NAME a DBA-Doing Business N) (b315 FACILITY 10e <br /> lxll IMO1 WYE VUZX nv <br /> NEAREST CROSS STREET ,.j401 g6WO AGILITY OWMER TYPE F 4. LOCAL AGENCYIDISTRICT' <br /> r /a "f 4411'�i CORPORATION r S. COUNTY AGENCY' <br /> BUSINESS TYPE F L GAS STATION./ r 3.FARM r S.COMMERCIAL r 2. INDIVIDUAL r 8. STATEAGENCY- <br /> F 2.DISTRIBUTOR F 4.PROCESSOR 4:05.OTHER F 3. PARTNERSHIP F 7. FEDERAL AGENCY' 402 <br /> 403 <br /> TOTAL NUMBER OF TANKS Is facility on Indian Reservation or 'If owner of UST is a Public agency:name of supervisor of <br /> REMAINING'AT SITE trustlands? division,section or office which operates the UST. <br /> (This is the contact person for the tank records.) <br /> 404 F <br /> Yes �a 405 406 <br /> It.PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 � <br /> �1AI PHONE 408 - <br /> MAILING OR STREET ADDRESS 409 I 1 <br /> 1�� <br /> CITU 410 TATE 411 21P CODE 412 <br /> e1raSS �alIe CA 0115-�14s <br /> PROPERTY OWNERTYPE F 2. INDIVIDUAL F 4. LOCAL AGENCY/DISTRICT F 6. STATEAGENCY 413 <br /> F 1. CORPORATION PARTNERSHIP F 5. COUNTYAGENCY F 7. FEDERAL AGENCY <br /> 10.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 I Vs s PHONE 415 <br /> LA k I 5 Lri ,fo4b <br /> MAILING OR STREET ADDRESS 416 Y/t O. f�OX I D-7 <br /> CITY 41 Va I l2 CTATE.4 I 418 ZIP CODE 419 <br /> (3625,5 15q 45 <br /> TANK OWNER TYPE F 2. INDiviDuAl. r 4. LOCAL AGENCY I DISTRICT F 6. STATE AGENCY 420 <br /> F 1. CORPORATION i PARTNERSHIP r 5. COUNTY AGENCY r 7. FEDERALAGENCY <br /> 1%1 RCIAElnnpF(311AI17&TlnMllqTSTnRAr.FFFrArrniimTmllmgrg <br /> TY(TK)HO 1 4 4 - Call(916)322-9669 if questions arise 421 <br /> INDICATE METHOD(S) F 1. SELF-INSURED r 4. SURETY BOND F 7. STATE FUND yyF.�1_0�. LOCAL G�OV�=T��/E�Q/H1A�NIS�M}7� <br /> r 2. GUARANTEE F S. LETTER OF CREDIT F B. STATE FUND S CFO LETTER )1099 OTHERIM V✓•�1/1/✓/" <br /> F 3, INSURANCE r 6. EXEMPTION r 9. STATE FUND 8 CD 422 <br /> Chad,one box to indicate which address should be used for legal notifications and mailing. r 1. FACILITY PROPERTY OWNER r 3. TANK OWNER 423 <br /> Legal n.tificlitions mailin ,It W sent to the tank nar unless too.1 or ed <br /> I,11. Plot 11ANT qlr.NATI IRF <br /> Certification'. I certify that fin ir4onnalion provided herein is We and accurate to the best of my knowledge. <br /> SIGNATURE OF APPLICANT DATE 424 1 PHONE 425 <br /> NAME OF APPLICANT(arid) 426 TITLE OF APPLICANT 427 <br /> STATE UST FACILITY NUMBER(Forklcal use only) 428 1998 UPGRADE CERTIFICATE NUMBER(For lace/use ody) 429 <br /> UPCF(1199 revised) 3 _/ I <br /> 6 'a_q_ q/q Fofrnerty SWRCB Fofm A <br />