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0­7ED PROGRAM CONSOLIDATED FORM G5' ZZ D� <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - Ft-IL1 j page per site) �gc_of_ <br /> 5.CHANGE OF L�FOR�tATION C17.PERMANENTLY CLOSED SITE <br /> CTION (�I.NEW PERM [3IT 3•RENEWAL PERMIT ❑ ❑8.TANK REMOVEI <br /> TYPE OF A > <br /> a3 <br /> �• [34.AMENDED PERMIT (Specify change) <br /> (Check one item only) ❑6,TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION <br /> BUS INESS NAME(Sane as FACILITY NAME or DBA-Doing Business As) 3. FACILITY 1. <br /> Gkla I l 6 3 5 <br /> 401. FACILITY Ow- R TYPE 4.LOCAL AGENCY/DISTRICT» 407 <br /> I,-EAREST CROSS TREET <br /> -� 1.CORPORATION ❑5.COUNTY AGENCY- <br /> Bl SINESS GAS STATION 3.FA 5.COMMERCIAL 403. ❑2.INDIVIDUAL ❑6.STATE AGENCY` <br /> 4.PROCESSOR ❑6.OTHER ❑3.PARTNERSHIP ❑7.FEDERAL AGENCY* <br /> TYPE ❑2.DISTRIBUTOR ❑ up 406. <br /> Is <br /> facility on Indian Reservation nos. 'If owner of UST is a public agency: name of supervisor of division section or <br /> TOTAL NUMBER OF TANKS 406 office which opemms the UST. (This is the contact person for the tank records.) <br /> REMAINING AT SITE or vast lands? <br /> E3 Yes <br /> No <br /> II. PROPERTY OWNER INFORALkTION <br /> 407. PHONE ^ aoa. <br /> PROPERTY OWNER NAME _ <br /> 409. <br /> 14.4,1ENG OR STREET A, DRESS 0O A ^O <br /> /c U 410. STATE alt ZIP COD 412.c 17: <br /> CITY <br /> ATE AGEN 413. <br /> PROPERTY OWNER TYPE CORPORATION 0 3.PARTNERSHIP ❑5.COUNTY AGENCYDIVIDUAL 4.LOCAL AGENCY/DISTRICT ❑7.FEDERAL AGENCY <br /> M.TANK OWNER INFORMATION <br /> ala. PHONE 415. <br /> TANK OWNER NAME S- <br /> 416. <br /> MAILING OR STREET ADDRH <br /> CITY 417. STATE ata.7ZIPCO_DE� _ <br /> o C"- cl 3rL © Z <br /> TANK OWNER TYPE 1.CORPORATION 2.INDIVIDUAL 4.LOCAL AGENCY/DISTRICT 6.STATE AGENCY 420. <br /> El 3.PARTNERSHIP E]5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> TV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY TK)H 44- Call(916 322-9669 if questions arise 421. <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ❑1.SELF-INSURED 0 4.SURETY BOND ❑7.STATE FUND ,2r+o•LOCAL GOVT MECHA.N'ISM 422. <br /> ❑2.GUARANTEE ❑5.LETTER OF CREDIT ❑8.STATE FUND&CFO LETTER [199.OTHER: <br /> ❑3.INSURANCE ❑6.EXEMPTION ❑9.STATE FUND&CD <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Cbeck one box to indicate which address should be used for legal notifications and tailing. 423. <br /> Legal notifications and mailings will be.sent to the tank owner unless box 1 or 2 is checked X, <br /> .FACILITY [:12. PROPERTY OWNER ❑3.TANK OWNER <br /> VII.APPLICANT SIGNATURE <br /> Certification: I certify that the information prodded herein is true and accurate to the best of my knowledge. 425 <br /> DATE azo. PHONE <br /> SI RE OF LI TE PL <br /> 426• TITLE(5FAPPLICA14T <br /> 427. <br /> STATE UST FACILITY UMBER(Agency use only) <br /> 428. 1998 UPGRADE CERTIFICATE NUMBER(Agency use only) <br /> 429' <br /> (See Data Element 1,above. Cly 72 57 <br /> �Zo � � t Ste' � _ <br /> N h"p://www.unidocs.org <br /> Rev.02/16/90 <br /> UPCF Hwfwrc-a(1/99)-1/2 �,�� <br />