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'IED PROGRAM CONSOLIDATED FOIW <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (One page per site) Page_of <br /> TYPE OF ACTION A L NEW PERMIT ❑3.RENEWAL PERMIT ❑S.CHANGE OF INFORMATION ❑7.PERMANENTLY CLOSED SITE 400 <br /> (Check one item only) ❑4.AMENDED PERMIT (Specify change) ❑8.TANK REMOVED <br /> ❑6.TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3. FACILITY <br /> �?Go L,L.-.I Ty c>sz-4 ( <br /> (.P _l ID# <br /> NEAREST CROSS STREET401. FACILITY OWNER TYPE ❑4.LOCAL AGENCY/DISTRICT* 40'_ <br /> �L3eSIk�l��'(T6u ;T �K1.CORPORATION ❑5.COUNTY AGENCY* <br /> BUSINESSJK 1.GAS STATION ❑3.FARM ❑5.COMMERCIAL 403. ❑2.INDIVIDUAL [:16.STATE AGENCY* <br /> TYPE [12.DISTRIBUTOR ❑4.PROCESSOR ❑6.OTHER ❑3.PARTNERSHIP ❑7.FEDERAL AGENCY* <br /> TOTAL NUMBER OF TANKS 404. 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 SITE 3 or trust lands? office which operates the UST. (This is the contact person for the tank records.) <br /> ❑Yes A No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 40, PHONE 408. <br /> IJE'SZ" Cc4-St ppn�_-)Uc. S <br /> MAILING OR STREET ADDRESS 409 <br /> 4' <br /> 410. ST C� a,t. ZIP 9atz. <br /> CITY LA Pkl RA, <br /> PROPERTY OWNER TYPE 1.CORPORATION ❑2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 413. <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE a,5 <br /> � � C <br /> �sT otes; +��n��-c s <br /> MAILING OR STREET ADDRESS 416 <br /> CITY j , A 417. STATE 411. ZIP CODE 90(C;;a-F:;0 419 <br /> TANK OWNER TYPE 1.CORPORATION ❑2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT [:16.STATE AGENCY ago. <br /> [13.PARTNERSHIP ❑5.COUNTY AGENCY [:17.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 1 1 1 1 1 1 1 Call 916 322-9669 if questions arise 421 <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) '�A1.SELF-INSURED [14.SURETY BOND ❑7.STATE FUND ❑10.LOCAL GOVT MECHANISM 422 <br /> ❑2.GUARANTEE [15.LETTER OF CREDIT ❑8.STATE FUND&CFO LETTER ❑99.OTHER: <br /> [13.INSURANCE [16.EXEMPTION ❑9.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 mailing. <br /> Legal notifications and mailings will be sent to the tank owner unless box I or 2 is checked. ❑ 1.FACILITY P(2. PROPERTY OWNER ❑3.TANK OWNER 423 <br /> VII.APPLICANT SIGNATURE <br /> Certification: I certify that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNATURE OF APPLICANT C DATE 424. PHONE 425, <br /> 3 Zq 0�0 R l C r�-CoCo`� 1$2-7 <br /> NAME OF APPLICANT(print) 426. TITLE OF APPLICAN 427. <br /> D; �87N-r �o7z o�Ji�l6'� <br /> STATE UST FACILITY NUMBER(Agency use only) 428. 1998 UPGRADE CERTIFICATE NUMBER(Agency use only) 47 <br /> (See Data Element 1,above. <br /> UPCF Hwfwrc-a(1/99)-1/2 http://www.unidocs.org Rev.02/16/00 <br />