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TED PROGRAM CONSOLIDATED FORM <br /> TANKS IL <br /> UNDERGROUND STORAGE TANKS - F`XC <br /> (One page per site), �'. � of <br /> TYPE OF ACTION (�1.NEW PERMIT ❑3.RENEWAL PERMIT ❑5.CHANGE OF L\7 OR�iATION ❑❑8.PERMANENTLY <br /> REMOVED <br /> ASID <br /> ❑4.AMENDED PERMIT (Specify change) <br /> (Cbeck one item only) C3 6.TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3. FACILITY I. <br /> ID# <br /> NEAREST CROSS TREET �t7 �, OYl ao1. FACILITY OW`N'ER TYPE 4.LOCAL AGENCY/DISTRICT* 402 <br /> K �n S.CORPORATION [35.COUNTY AGENCY' <br /> BUSINESS GAS STATION 3.FA 5.COMMERCIAL ao3. ❑2.INDIVIDUAL ❑6.STATE AGENCY* <br /> 4.PROCESSOR ❑6.OTHER El 3.PARTNERSHIP 137.FEDERAL AGENCY' <br /> TYPE [3 2.DISTRIBUTOR ❑ up ao6. <br /> Is facility on Indian Reservation 4os. •If owner of UST is a public agency:name of supervisor of division.section or <br /> TOTAL NUMBER OF TANKS 40° ry office which operates the UST. (This is the contact person for the tank records.) <br /> REMAINING AT SITE or trust lands? <br /> ❑Yes No <br /> II. PROPERTY OWNER INFORMATION <br /> 407• PHONE nos. <br /> PROPERTY OWNER NAME _ J ri.e 4o,-'s" <br /> •-� l� � alp v <br /> 409. <br /> �L ILING OR STREET DRESS "xv. �/�G �A�O <br /> /U/T aro. STATE 411 ZIP COD / 412 <br /> criY <br /> �.-�. < .. <br /> �C Lam" � �� DIVIDUAL [3 4.LOCAL 41 3. <br /> PROPERTY OWNER TYPE CORPORATION ❑3.PARTNERSHIP ❑5.COUNTY AGENCY 7. <br /> ❑7.FEDE�AGENCY <br /> III.TANK OWNER INFORMATION <br /> a <br /> TANK OWNER NAME ta. PHONE 415. <br /> 416. <br /> MAILING OR STREET ADDRE <br /> �4yl/. 419. <br /> CITY 417. STATE 419. ZIP CODE <br /> o L_ 4 rl � �- - <br /> TANK OWNER TYPE 1.CORPORATION 2.INDIVIDUAL 4.LOCAL AGENCY/DISTRICT 6.STATE AGENCY azo. <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> IV.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-INSUkED ❑4.SURETY BOND ❑7.STATE FUND o.LOCAL GOVT MECHA.V"ISM az2. <br /> •ot <br /> ❑2.GUARANTEE ❑5.LETTER OF CREDIT ❑g.STATE FUN*)&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. / 42, <br /> Legal notifications and mailings will be sent to the tank owner unless box 1 or 2 is checked. X 1.FACILITY [32. PROPERTY OWNER ❑3.TANK OWNER <br /> VII.APPLICANT SIGNATURE <br /> Certification: I certify that the information provided herein is true and a uratc to the best of my knowledge. 425 <br /> SI RE OF P C DATE ata. PHONE <br /> Z O C $� <br /> TcNT(print) 426. TITLEF PLICA 427. <br /> WAME OF APPLO / <br /> C( <br /> FSTATE UST FACILITY UMBER(Agency use only) �� <br /> a2s. 1998 UPGRADE CERTIFICATE NUMBER(Agencyuse only) 429 <br /> ata Element 1,above. C Q <br /> 7 5 <br /> r <br /> L•PCF Hwfwrc-a(1/99)-1/2 ., <br /> http://www.unidocs.org Rev.02116/00 <br /> ti <br />