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JIFIED PR' CONSOLIDATED F 2 -7 -7 p - t/ <br /> TAh.'Cb zl�7 wt 0 <br /> UNDERGROUND STORAGE TANKS - F C L <br /> 0 e page per site) Page_of_ <br /> TYPE OF ACTION NEW PERMIT ❑3.RENEWAL PERMIT ❑S.CHANGE OF INFO7.PERMANENTLY CLOSED SITE 400. <br /> (Check one item only) ❑4.AMENDED PERMIT (Specify change) 8. ANK OVED <br /> ❑6.TEMPORARY SITE CLOSURE V�'G V,r �%t <br /> FACILITY/SITE INFORMATIO E M i/)�- ��/ l <br /> BUSINESSNAMEttS.ne m,ks !Lrry NANMo DBA-Doing Eminms As) 3. FACILITY <br /> IDR <br /> NEAREST CROSSTREET 4o1. FACILITY OWN ER TY PE 4.LOCAL AGENCY/DISTRICT• 402 <br /> T� K CORPORATION ❑5.COUNTY AGENCY' t <br /> BUSINESS I.GAS STATION LJ3.FARM EIS.COMMERCIAL 403. ❑2.INDIVIDUAL [16.STATE AGENCY- C I//YIZClf <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR�S..OTHER ❑3.PARTNERSHIP [17.FEDERAL AGENCY• <br /> TOTAL NUMBER OF TANKS 4a• 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 SI or trust lands? office whicherates the UST. <br /> op (This is the contact person for the tank records.) <br /> 6, ❑Yes PAO <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTYOWNER NAM4 4oz PHONE 409 <br /> S _ J tom© 66s3�i <br /> MAILING OR STREET ADDRESS 4WCITY ©� no. STATE 411. ZIP CODE 412. <br /> Owl/ vY <br /> 11S' c.?-O Z <br /> PROPERTY OWNS TYPE LJI.CORPOPATION 2.INDNIDUAL Lj 4.LOCAL AGENCY/DISTRICT Ll 6.STATE AGENCY 413, <br /> GC11 17 <br /> G ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> s <br /> MAILING OR STREET ADDRESS - 416. <br /> CITY n7. STATE 418. ZIP CODE 419. <br /> TANK OWNER TYPE U I.CORPORATION 2. El 4.LOCAL AGENCY/DISTRICT-- 6.STATE AGENCY 420. <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY [17.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) 01.SELF-INSURED ❑4.SURETY BOND ATE FUND ❑to.LOCAL GOVT MECHANISM 4a <br /> ❑2.GUARANTEE [15.LETTER OF CREDIT ❑8.STATE FUND&CFO LEITER ❑99.OTHER: <br /> ❑3.INSURANCE ❑6.EXEMPTION 119.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 nvs7ing. -/ <br /> Legal ortifintiom and mailings will be sent to the tank owner unless box 1 ort is checked Ami.FACILITY ❑2. PROPERTY OWNER ❑3.TANK OWNER 413. <br /> VII.APPLICANT SIGNATURE <br /> Certification: I certify that the inforrnationnv' ed herein is true nd accurate to the best of my knowledge. <br /> SIGNATURE OF APPLICANTDATE iz y HONE. 425. <br /> m <br /> _ZG�S3 <br /> NAME OF APPLICANT(print) 426. TITLE PL ANT 427. <br /> /F / FS <br /> STATE UST FACILITY NUYAER(Agency me only) 428. 1998 UPGRADE CERTIFICATE NUMBER(Agency ma Dory) 429. <br /> (See Data Element 1,above. <br /> UPCF Hwfwre-x(1/99)-1/2 http://was .unidocs.org Rev.02/16/00 <br />