Laserfiche WebLink
UIRED PROGRAM CONSOLIDATED FOWI <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page per site) Page_of <br /> TYPE OF ACTION ❑ 1.NEW SITE PERMIT ❑3.RENEWAL PERMIT ❑5.CHANGE OF INFORMATION ❑ 7.PERMANENTLY CLOSED <br /> (Check one item only) ❑4.AMENDED PERMIT specify change local use only ❑ 8.TANK REMOVED 6 <br /> ❑&TEMPORARY SITE CLOSURE 400 <br /> 0 oz Z <br /> I. FACILITY / SITE INFORMATION <br /> BUSINESS NAME(some u FACQ7IY WAW or DBA-Doma BuOen As) 3 FACILITY IDI9T <br /> / I <br /> 13 <br /> �t-Cc& 2l t� k'_ t0 7 <br /> NEAREST CROSS STRn 401 FACILITY OWNER TYPE Ll 4.LOCAL AGENCY/DISTRICT' <br /> w ❑ 1.CORPORATION ❑ 5.COUNTY AGENCY' <br /> BUSINESS I.GAS STATION Lj 3.FARM Lj 5. COMMERCIAL ❑ 2.INDIVIDUAL [16.STATE AGENCY* <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR❑6. OTHER 403 ❑ 3.PARTNERSHIP ❑7.FEDERAL AGENCY' 402 <br /> TOTAL NUMBER OF TANKS Is facility on Indian Resmation or •If owner of UST is a public agency:name of supervisor of division,section or office which <br /> REMAINING AT SITE mtstlands7 operates the UST(This is the contact person for the tank records.) <br /> 4a ❑ Yes ❑ No ---- <br /> __ 403 406 <br /> II. PROPERTY O R INFORMATION <br /> PROPERTY OWNER NAME 407 - 408 <br /> MAILING OR STREET ADDRESS 409 <br /> CITY 410 STATE 411 ZIP CODE +12 <br /> 6 ),LiL 414c, �) <br /> PROPERTY OWNER TYPE I.CORPORATION tF72ANDIVIDUAL Lj 4.LONCAL'AGENCY/DISTRICT 6.STATE AGENCY <br /> ❑3.PARTNERSHIP [-15.COUNTY AGENCY ❑7.FEDERAL AGENCY 413 <br /> III. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 415 <br /> CONE <br /> 7�Ll 7v <br /> �) 416 <br /> MAILING OR ADDRESS <br /> Ox j � <br /> CITY <br /> t <br /> 417 STATE , 419 ZIP CODE 419 <br /> TANK OWNER TYPE 1.CORPORATION 2,INDIVIDUAL 4.LOCAL AGENCY/DISTRICT 6.STATE AGENCY 420 <br /> ❑3.PARTNERSHIP ❑S.COUNTY AGENCY ❑ 7.FEDERAL AGENCY <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY TK HQ 44- C - Call 916 322-9669 if questions arise 421 <br /> V. PETROLEUM UST F 4ANCIAL RESPONSIBILMY <br /> INDICATE METHOD(s .SELF-INSURED ❑4.SURETY BOND ❑7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM <br /> ❑2.GUARANTEE ❑5.LETTER OF CREDIT ❑8.STATE FUND&CFO LETTER ❑ 99.OTHER: <br /> ❑3.INSURANCE [-16.EXEMPTION ❑9.STATE FUND&CD 422 <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 ❑2. PROPERTY OWNER 3.TANK OWNER 423 <br /> VII. APPLICANT SIGNATURE <br /> Certification-1 certify that the information provided rein is true and accurate to the best of my knowledge. <br /> SIGN O APPLICANT DATE 424 PHONE 4zs <br /> N PL ANT(print) 426 TITLE OF APPLICANT / n`J�J 427 <br /> STATE UST FACILITY NUMBER(For 10 1 use oety) 428 1998 GRADE CERTIFICATE NUMBER(For 1 c 1 use Daly) +z9 <br /> UPCF(1/99 revised) 8 Formerly SWRCB Form A <br />