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NIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (One page per site) Page of D1 <br /> /9 <br /> I <br /> TYPE OF ACTION ❑1.NEW PERMIT 193.RENEWAL PERMIT [15.CHANGE OF INFORMATION ❑7.PERMAN <br /> (Check can item only) ❑4.AMENDED PERMIT (Specify change) ❑8.TANK REM <br /> ❑6.TEMPORARY SITE CLOSURE <br /> 7 200 <br /> I. FACILITY/SITE INFORMATION E LTH <br /> BUSINESS NAME(se,,,a as FAealry NAMB or DBA-13alag Business As) 3. FACILITY V C S <br /> SrRrltkW dbaTmcoTauckPlkz ID# PE MI IS �. <br /> NEAREST CROSS STREET i' 4o1. ,F,.A,/CILITY OWNER TYPE ❑4.LOCAL AGENCY/DISTRICT- -2 <br /> XA e-KTO N E (Zd w }I 1 W A J Lal I.CORPORATION ❑5.COUNTY AGENCY• <br /> BUSINESS 1.GAS STATION 3.FARM 5.COMMERCIAL 403. <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR ❑6.OTHER ❑2.INDIVIDUAL ❑6.STATE AGENCY* <br /> ❑3.PARTNERSHIP ❑7.FEDERAL AGENCY• <br /> TOTAL NUMBER OF TANKS 4W. Is facility on Indian Reservation 405. •If owver of UST u a public agency:mme of supervisor of division,section or sob. <br /> REMAINING/AT SITE or trust laralss? office which operates the UST. (This is the contact person for the tank records.) <br /> / ❑Yes LYS No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 408 <br /> Li-XI AN TR Gs'o - 6 /� - 3Ns6 <br /> GOR STREET ADDDRESS aw <br /> 2-614 141CIgOLLE C-V <br /> CITY <br /> r-� <br /> Oto. STATE 411. ZIP CODE 412. <br /> SouTH �AW 1'IGANCISLC eA 9gDSD <br /> PROPERTY OWNER TYPE L CORPORATION LJ 2.INDIVIDUAL 4.LOCAL AGENCY/DISTRICT 6.STATE AGENCY 413. <br /> Lye.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 4u. PHONE 415 <br /> M90L mp N �V J,SD- bah -3 s6 <br /> 1N OR STREET ADDRESS 436. <br /> �T7- MICHrr L .E e+. <br /> c7e u-rH 6A N FIZA ti/Gr sca STA TIa A 418. ZIP CODs os o 419. <br /> TANK OWNER TYPE ❑ I.CORPORATION El 2.INDIVIDUAL L1 4.LOCAL AGENCY/DISTRI <br /> C/�/T [:16.STATE AGENCY 420. <br /> W'S.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY 3.1F H 44- I O jo Call 916 322-9669 if questions arise 421. <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ❑L SELF-INSURED ❑4.SURETY BOND [17.STATE FUND ❑10.LOCAL GOVT MECHANISM <br /> 11 <br /> ❑2.GUARANTEE [IS.LETTER OF CREDIT 56.STATE FUND&.CFO LETTER ❑99.OTHER: __ <br /> ❑3.INSURANCE ❑6.EXEMPTION [19.STATE FUND&CD <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one box to indicate which address should be used for legal notificatiore and mailing. �,,/ <br /> Legal notifications and mailings will be sent to the tank owner unless box 1 or 2 is checked. El i.FACILITY [12. PROPERTY OWNER pp 3.TANK OWNER 423_ <br /> VII.APPLICANT SIGNATURE <br /> Certification: 1 certify that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNATW OF APPLICDATE j 424. PHONE 42T. <br /> 4_Yt .- 413IP3 G.SD- 614 -35/S6 <br /> NAME APPLICANT(print) V 426. TITLE OF APPLICANT 427. <br /> 40L M /A.V./ JAIVE-F AF;kEt. bsK MANAGE2 <br /> STATE UST FACILITY NUMBER(Agency ase only) 42a 1998 UPGRADE CERTIFICATE NUMBER(Agency ose oaly) 42a <br /> (See Data Element 1,above. <br /> UPCF Hwfwrc-a(1/99)-1/2 http://www.unidocs.org Rev.02/16/00 <br />