Laserfiche WebLink
i'Ni PROGRAM CONSOT.TDATF,D FORM ■� _ _ _ , _�� <br /> �T I, <br /> :ACnON <br /> UNDERGROUND STORAGE TANKS - FAC uJ310 <br /> (one page per site) Page_of_TYPE OF ja\1.NEW SITE PERMIT 3.RENEWAL PERMIT ❑5.CHANGE OF INFORMATION ❑ 7.PERMANENTLY CLOSED SITE <br /> (Check one dent 0111Y) (]4.AMENDED PERMIT specify change IoW use ody ❑ 8.TANK REMOVED <br /> ❑6.TEMPOKARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION <br /> BUSINESS <br /> USS NAME(s®ea,FACHITYNAMEor DBA-Doral Burbm A41 L FACILITY IDN 1 <br /> /1 r &157 <br /> NEAREST „S `I01 FACILITY OWNER TYPE 4.LOCAL AGENCY/DLSTRICP <br /> [��"/Y ❑ I.CORPORATION ❑5.COUNTY AGENCY" <br /> BUS 1.GAS STATION 3.FARM . COMMERCIAL ❑ 2.INDIVIDUAL ❑6.STATE AGENCY' <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR❑6. OTHER 4m ❑ 3.PARTNERSHIP ❑7.FEDERAL AGENCY' <br /> TOTAL NUMBER OF TANKS is facility on Indian Reservation or 'If owm of USf u a public ag=cy:name of supervisor of divisive,sewoo or ofi¢c which <br /> REMAINING AT SITE trslstlands? opernes the UST(Tha is the comet person for the tank records.) <br /> 4w ❑ Yes 7No 405 406 <br /> II. PROPERTY OWNER INFORMATION <br /> I PROPERTY OWNER rjIAAdt 9P1 PHONE °os <br /> ?.� 7123SG <br /> MAD.ING ORSTREET ADD RES S <br /> Z <br /> CITY °10 STATE alt ZIP CODE 4¢ <br /> c 7� =, E <br /> PROPERTY OWNER TYPE U 1.CORPORATION Ll 2.INDIVIDUAL 4.LOCAL AGENCY/DISTRICT Ljb.blAlEAGENCY <br /> -g;�-PARTNERSHIP D 5.COUNTY AGENCY ❑7.FEDERAL AGENCY 411 <br /> III.TANK OWNER INFORMATION <br /> TA` RNAME 414 PHONE Z 411 <br /> Nf / 416 <br /> MAILING R STREET ADD S <br /> ZZ , . <br /> CITY4v STA(T /// ne ZIP CODE a9 <br /> TANK OWNER TYPE Lj I.CORPORATI )-N--:72INDIVIDUAL 4.LOCALAGENCY/D[.STRIC'T 6.STATE OE all <br /> 3.PARTNERSHIP D 5.COUNTY AGENCY D 7.FEDERAL AGENCY <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44 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 D 10.LOCAL GOVT MECHANISM <br /> ❑2.GUARANTEE ❑5.LETTER OF CREDIT ❑S.STATE'FUND&CFO LEITER ❑ 99.OTHER: <br /> %2;4.INSURANCE ❑6.EXEMPTION ❑9.STATE FUND&CD 4z: <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Cbeak are box a i or=which address should de used for legal notifications and mailing. <br /> Legal notifwtions and mailings will be sent to the ank owner unless box 1 or 2 is checked. 0-rFACILI Y ❑2. PROPERTY OWNER ❑3.TANK OWNER 421 <br /> VII.APPLICANT SIGNATURE <br /> Ceruficaucn-I fy that the info Ito nrovidad heroin is v e d ammo a Nc best of my knowledge. <br /> DA 034 PHO 4u <br /> SIGNATU P ICA 11 7 --c 0/ / Z�� <br /> y CEJ ✓ 4n <br /> N OF PLICANT pnn TITLE OF APPLICANT <br /> G F <br /> STATE UST FACILITY NUMBER 1Fer mal c adyl 4N 11998 UPGRADE CERTIFICATE NUMBER(Fa mal re ouy) <br /> UPCF(1/99 revised) 8 Formerly SWRCB Form A <br /> 1 <br />