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iiNTT orCOMNSOi.iDATF.D FORMFACI1' <br /> UNDERGROUND STORAGE TANKS - <br /> -(one page pa sire) Page-of- <br /> [] <br /> agc_of_ SZ <br /> TYPE OF A10N �1.NEW SITE PERMlT O 3.RENEWAL PERMIT ❑5.CHANGE OF INFORMATION O 7.PERMANII`TLY CLOSED SITE <br /> Chao local use ody. ❑ S.TANK REMOVED <br /> k one ice+o Jy) [14.AMENDED PERMIT ipwfy Ee aro <br /> (�" ❑6.TEMPORARY SITE CLOSURE toli(lay <br /> I. FACILITY/SITE INFORMATION 1 <br /> N� rJ CILI 40 <br /> BUS A (S wFACUXrY Nw��BA-Demi Bu®raa Nl F / <br /> (O sol FAC6ITY OWNER TYPE 4.LOCAL AGENCY/DLSIRICT�bl)� IU4 <br /> RFe'r CR, QS n^ [ ❑ 1.CORPORATION ❑5.COUNTY AGENCYI <br /> COtvIIdERCIAL ❑ 2.INDIVIDUAL ❑6.STATE AGENCY' <br /> BUS 1.GAS STATION 3.FARM 9.PARTNERSHIP 0 7.FEDERAL AGENCY' 4w <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR❑6. OTHER am ❑ <br /> ER OF TANKS H facility on Indian Reservation or 'If owner of UST is a public agency:rank of r the tank of orde.)o,aeaioa or rffrz which <br /> TOTAL NUMB ., opaata We UST Crhls is the eovuet yersor for the ark recoNs) <br /> REMAINING AT SITE nveUandt7 +a <br /> 4r+ ❑ Yes yNo <br /> II. PROPERTY OWNER INFORMATION <br /> am PHONE <br /> t <br /> PROPERTY OWNER AME L <br /> � aw <br /> MAIL✓TNG OR STREET ADD&-&147r-,I <br /> ,S.a <br /> '�� 1 •lo STATE *U ZIP CODE- au <br /> clrY G C /U N ' G/1 <br /> PROPERTY WNER TYPE I.CORPORATION �PP Rl��VIDUAL IP ❑5.COCUNTY AAL GENCY CY I ��� ❑7.FEDERAL AGENCY aO <br /> III.TANK OWNER INFORMATION <br /> 414 PHONE / 411 <br /> TANK RNAME .GAY' -4 Z <br /> NNI rat <br /> MAILING R STREET ADD S <br /> ZZc/yQ n n, <br /> W �` ` �V/ 41a ZIP CODE 415 <br /> an STATECITY <br /> TANK OWNER TYPE I.CORPORATION 2.INDIVIDUAL 4.LOCAL AGENCY/DISTRICT 7.FEDERAL AGENCY 4m <br /> 3 .PARTNERSHIP ❑5.COUNTY AGENCY ❑ <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY (TK)H <br /> Call 916 322-9669 if questions arise <br /> al <br /> 44- <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ❑ 1.SELF-INSURED ❑4.SURETY BOND ❑7.STATE FUND <br /> ❑10.LOCAL GOVT MECHANISM <br /> ❑2.GUARANTEE El 5.LETTER OF CREDIT [38.STATE FUND&CFO LEITER ❑ 99.OTHER: m <br /> *54.INSURANCE [36.EXEMPTION [19.STATE FUND&CD <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Chat ate on to indicate which addressshould be used for leg all I olificau,os and trailing. FAC'II.1T'Y ❑2. PROPERTY OWNER ❑3.TANKOWNER <br /> 1 I notifications and railings will be sem to the tank ower nunless box 1 or 2 is ch-ekeL <br /> VII.APPLICANT SIGNATURE <br /> Cenifiation-1 fy thatrhe info 'tio nrovided herein is true d accurate lethe best of my knowledge. _ ay PHO 42s <br /> SIGNATU P ICA DAT .e 6 3r6 <br /> ale TITLE OF APPLICANT <br /> N OF PLICANT print <br /> G F 2 E n/oG0 •p <br /> STATE UST FACILITY NUMBER 1Foe hal only) 'n 11998 UPGRADE CERTIFICATE NUMBER(Fwloeal axonly) <br /> UPCF(1/99 revised) <br /> 8 Formerly SWRCB Form A <br /> 1 <br />