Laserfiche WebLink
Ad1h J11111111, <br /> U FIED PROGRAM CONSOLIDATED -RM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page per site) <br /> Page _ of _ <br /> TYPE OF ACTION r 1.NEW SITE PERMIT r 3.RENEWAL PERMIT r 5.CHANGE OF INFORMATION(Specify change- r 7.PERMANENTLY CLOSED SITE <br /> (Check one item only) r 4.AMENDED PERMIT local use only) r 8.TANK REMOVED 400 <br /> F 6.TEMPORARY SITE CLOSURE <br /> I.FACILITY I SITE INFORMATION <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 FACILITY IO e <br /> /4wmr 9 elvue-f 'r 'tGV-r!s 13 913 <br /> STREef MOtareiiiiiiS FACILITY OWNER TYPE r 4. LOCAL AGENCY/DISTRICT' <br /> Q. N' pn-w \ 2 Al. CORPORATION r 5. COUNTYAGENCY` <br /> BUSINESS TYPE 1.GAS STATION r 3.FARM r 5.COMMERCIAL r 2. INDIVIDUAL r 6. STATE AGENCY' <br /> r 2.DISTRIBUTOR r 4.PROCESSOR FS OTHER r 3. PARTNERSHIP r 7 FEDERAL AGENCY' 402 <br /> 403 <br /> TOTAL NUMBER OF TANKSla facility on Indian Reservation or 'If owner of UST is a public agency.name of supervisor of <br /> REMAINING AT SITE trusllands7 division,section or office which operates the UST. <br /> 3 (This is the contact person for the tank remrdsJ <br /> 404 r Yes J 4o 405 4M <br /> II.PROPERTY OWNER INFORMATION <br /> PROPEROWNER <� PH'z��4008 <br /> MAILING OR STREET ADDRESS 409 <br /> CITY 410 STATE 411 ZIP CODE 412 <br /> /7f/N710 Cr3 , �S33 <br /> PROPERTY OWNER TYPE �4 r 2. INDIVIDUAL r 4. LOCAL AGENCY/DISTRICT r 6. STATEAGENCY 413 <br /> Y1. CORPORATION F 3. PARTNERSHIP r S. COUNTYAGENCY r 7. FEDERALAGENCY <br /> // III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> o Sit.✓J��N 2uq_ y39 -'1S3a <br /> MAILINGOR STREET ADDRESS 416 <br /> S10 r-1' 1-;,w;,) <br /> CITY 417 STATE 418 ZIP DE 419 <br /> ANT£Cs9. C•4 CA . 9S33E <br /> TANK OWNER TYPE ...---///III r 2. INDIVIDUAL r 4. LOCAL AGENCY/DISTRICT r S. STATE AGENCY 420 <br /> p-'1. CORPORATION F 3. PARTNERSHIP r 5. COUNTYAGENCY I. 7. FEDERAL AGENCY <br /> TY CTK)HQ 4 4 1 Call(916)322-9669 if questions arise 421 <br /> INDICATE METHOO(S) r 1. SELF-INSURED r 4. SURETY BOND r 7. STATE FUND r 10. LOCAL GOV=T MECHANISM <br /> r 2. GUARANTEE r S. LETTER OF CREDIT S. STATE FUND d CFO LETTER r 99. OTHER: <br /> r 3 INSURANCE r 6. EXEMPTION r 9 STATE FUND 8 CD 422 <br /> Check one box to hidicate which atltlressshoultlbeused far legal notifications end mailiig. 1. FACILITY r 2. PROPERTYOWNER r 3. TANK OWNER 423 <br /> L al nohrlcatimv and <br /> ma=d be aant to the tank owner unless box 1 r is checked. <br /> 1111 A PPI If-ANT SIGNATI IRF <br /> Canihcalion'. I unify that the information provided herein is true and accurate to Ute best of my knowledge. oo <br /> SIGNATURE OF APPLICANT 2 <br /> DATE 424 PH69�231 ^ L�2! 425 <br /> L'i't <br /> NAME OF APPLICANT(pnnt) ��. 426 TITLE OFAPPLICANT427 <br /> ems✓ iI/✓I� �` `T'- � . <br /> STATE UST FACILITY NUMBER(Forloca/use only) 428 1998 UPGRADE CERTIFICATE NUMBER(Forlocal use only) 429 <br /> 20ZZ <br /> n <br /> UPCF(1/99 revised) 5 Formerly SWRCB Form A <br /> 0 <br />