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(FIED PROGRAM CONSOLIDATED FC <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (One page per site) Page_of(p <br /> TYPE OF ACTION [11.NEW PERMIT ❑3.RENEWAL PERMIT ❑5.CHANGE OF INFORMATION ❑7.PERMANENTLY CLOSED SITE 400. <br /> (Check one item only) [14.AMENDED PERMIT (Specify change) ❑8.TANK REMOVED <br /> ❑6.TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3. FACILITY <br /> Z) /tQhI- 5XY-5-� 5 TIC I ID# <br /> NEAREST CROSS STREET 401. FACILITY OWNER TYPE ❑4.LOCAL AGENCY/DISTRICT* 402. <br /> `) -f�7} cr!4_ ❑ 1.CORPORATION ❑5.COUNTY AGENCY* <br /> BUSINESS 1.GAS STATION ❑3.FARM 5.COMMERCIAL 403. P 2.INDIVIDUAL ❑6.STATE AGENCY* <br /> TYPE [:12.DISTRIBUTOR [:14.PROCESSOR ❑6.OTHER ❑3.PARTNERSHIP ❑7.FEDERAL AGENCY* <br /> TOTAL NUMBER OF TANKS 404. 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 the UST. (This is the contact person for the tank records.) <br /> ❑Yes 19 No <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER MME 407. PHONE 408. <br /> Tin e1 KC)OI --,-)Og <br /> MAILING OR STREET ADDRESS 409. <br /> Corocr"ldo LQQ <br /> CITY 410. rTATE 411_ ZIP CODE 412. <br /> I lrc`L C (0 <br /> PROPERTY O)WNER TYPE ❑ 1.CORPORATION 2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 413. <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME <br /> D,�, f ala. PHONE�\ �l als. <br /> Iro <br /> l QI -o (: C 10. <br /> MAILING OR STREET ADDRESS 416. <br /> CITY an. 1 STATE 418. ZIP CODE 419 <br /> ­_T�rGl; LA 9s3-1(0 <br /> TANK OWNER TYPE ❑ 1.CORPORATION V 2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 420. <br /> ❑3.PARTNERSHIP [15.COUNTY AGENCY [:17.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 RESPONSIBILITY <br /> INDICATE METHOD(s) ❑1.SELF-INSURED ❑4.SURETY BOND ❑7.STATE FUND ❑10.LOCAL GOV'r MECHANISM 422 <br /> [12.GUARANTEE ❑5.LETTER OF CREDIT ❑8.STATE FUND&CFO LETTER ❑99.OTHER: <br /> 3.INSURANCE ❑6.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 mailing. <br /> Legal notifications and mailings will be sent to the tank owner unless box I or 2 is checked. A 1.FACILITY ❑2. PROPERTY OWNER ❑3.TANK OWNER 423. <br /> VII.APPLICANT SIGNATURE <br /> Certification: I certify that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNA 170E OF APPLICA T / DAT 424 1 PHONE 425. <br /> (z <br /> OF APPLICANT(print) 426. TITLE OF APPLICANT 427. <br /> STATE UST FACILITY NUMBER(Agency use only) 428 1 1998 UPGRADE CERTIFICATE NUMBER(Agency use only) 429. <br /> (See Data Element 1,above. <br /> UPCF Hwfwrc-a(1/99)-1/2 http://www.unidocs.org Rev.02/16/00 <br />