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/"/" _3 TIMED PROGRAM C:ONSOI,ID,aTF.D FOtW rF TANKS UNDERGROUND STORAGE TANKS - FACILITY (one page per si eF"'z e_L of TYPE OF ACTION Al.NEW SITE PERMIT [13.RENEWAL PERMIT ❑5.CHANGE OF INFORMATION ❑ TPERMANENTLY CLOSED SITE (Check one item only) ❑4.AMENDED PERMIT specify change local use only ❑ 8.TANK REMOVED ❑6.TEMPORARY SITE CLOSURE 411 I. FACILITY/SITE INFORMATION BUSINESS NAME arae ss FACILITY NA`E or BA-Doing Business As) 3 FACILITY ID# Wil Tk�UA7 ! racy O�{ 4o1 FACILITY OWNER TYPE 4.LOCAL AGENCY/DISTRICT* Gran limc R. ❑ 1.CORPORATION ❑5.COUNTY AGENCY* BUSINESSVXI.GAS STATION ❑3.FARM Ej 5. COMMERCIAL ❑ 2.INDIVIDUAL ❑6.STATE AGENCY* TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR[16. OTHER 403 �3.PARTNERSHIP [17.FEDERAL AGENCY* 402 TOTAL NUMBER OF TANKS Is facility on Indian Reservation or *If owner of UST is a public agency:[tame of supervisor of division,section or office which REMAINING AT SITE trustlands? operates the UST(This is the contact penton for the tank records.) 404 ❑ Yes ❑ No 405 406 19. PROPERTY OWNER INFORMATION PR PERTY O NER AME 407 PHONE 408 AW k /�Ir, l(c q2S- MAILING OR STREET A DRESS / �� 409 o D (� G ` CITY 410 STATE 411 ZIP CODE f,/�fr 412 I t� Y PROPERTY OWNER TYPE ❑ 1.CORPORATION 2.INDIVIDUAL 4.LOCAL AGENCY/DISTRICT 6.STATE AGENCY 3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY 413 III.TANK OWNER INFORMATION TANK OWNER NAME a PHONE MAILING OR STREET ADDRY.SS 416 57d �o CITY ��/hal- 417 STATE ala ZIP CODE f �y 411, TANK OWNER TYPE Lj 1.CORPORATION 2.INDIVIDUAL Lj 4.LOCAL AGENCY/DISTRICT 6.STATE AGENCY 420 ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY TK HQ 44- 1 1 1 1 1 1 Call 916 322-9669 if questions arise 421 V.PETROLEUM UST FINANCIAL RESPONSIBILITY INDICATE METHOD(s) [11.SELF-INSURED [14.SURETY BOND [17.STATE FUND ❑ 10.LOCAL GOVT MECHANISM ❑2.GUARANTEE ❑5.LETTER OF CREDIT ❑8.STATE FUND&CFO LETTER ❑ 99.OTHER: 3.INSURANCE ❑6.EXEMPTION ❑9.STATE FUND&CD 422 VI.LEGAL NOTIFICATION AND MAILING ADDRESS Check one box to indicate which address should be used for legal notifications and mailing. Legal notifications and mailings will be sent to the tank owner unless box I or 2 is checked. ❑ 1.FACILITY ❑2. PROPERTY OWNER A13.TANK OWNER 423 VII.APPLICANT SIGNATURE Certification-I certify that the informa)q provided herein is true and accurate to the best of my knowledge. SIGNATURE OF APPLICANT DATE 424 PHONE /2425 S 43 NAME OF APPLICANT(p' 426 TITLE OF APPLICANT_ .. 427 � a(b STATE UST FACILITY NUMBER(Fopfocal use only) 428 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 UPCF(1/99 revised) 8 Formerly SWRCB Form A