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NIFIED PROGRAM CONSOLIDATED 11'9,1 <br /> r r TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (One page per site) Pagc_of_ <br /> t <br /> TYPE OF ACTION 1%I.NEW PERMIT ❑3.RENEWAL PERMIT ❑5.CHANGE OF INFORMATION ❑7.PERMANENTLY CLOSED SITE 4011. I-� <br /> (Check one item only) ❑4.AMENDED PERMIT (Specify change)_ ❑8.TANK REMOVED <br /> ❑6.TEMPORARY SITE CLOSURE <br /> I <br /> I. FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Same as FACILITY NAME orDBA-Doing Business As) 3. FACILITY _ T <br /> II <br /> 2. CAFe IDNf <br /> NEAREST CROSS STREET [[I � 401. FACILITY OWNER TYPEa7� ]TCAL AGENCY/DISTRICT* 402 <br /> tAr'R.K. I �. f:� ra Sl °� O'Z ❑ I.CORPORATION ❑5.COUNTY AGI?NCY* <br /> BUSINESS JX I.GAS STATION Lj 3. FARM LJ 5.COMMERCIAL, 4037 92.INDIVIDUAL ❑6.STATE?AGENCY* <br /> TYPE: ❑2.DISTRIBUTOR ❑4.PROCH?SSOR ❑6.OTHI?It ❑3.PARTNI'.RSHIP [17. FED'.RAL AGIiNC')'* <br /> TOTAL NUM13ER OF TANKS 414. 1s 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 or trust lands? office which operates the UST. ('Phis is the contact person for the tank records.) <br /> 3 ❑Yes 54 No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407, [PHONE arts <br /> rREO F_S FA►,.o 1 A,rt q0jr - Fo 4- - ctr. 3q <br /> MAILING OR STREET ADDRESS 41W <br /> 310 R,t A•K"E GT. <br /> CITY 410. STATE 411• ZIP CODE? ate <br /> P L e s 4$44 6,4 I C A 17 (/S-66 <br /> PROPERTY OWNER TYPE ❑ I.CORPORATION 192.INDIVibUAL Lj 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. 41s, <br /> R (a !=s FA&.061arnL�oI<- 8"o : - Fr39 <br /> MAILING OR STREET ADDRESS 416. <br /> - 3 / °-- -- ter�a�c CT - _ <br /> CITY 411. 1 STATE 418. ZIPCOOL -- - 419. <br /> PCEA-S �To�( C Sys 6 <br /> TANK OWNER TYPE; ❑ I.CORPORATION ®2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 420. <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑T FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- Call 916 322-9669 if questions arise 421. <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ❑ I.SELF-INSURED [14.SURETY BOND N 7.STATE FUND ❑ 10.LOCAL GOV"f MECHANISM 422 <br /> C]2.GUARANTEE C15.LEITER OF CREDIT [18.STATE FUND&CFO LNITEiR ❑99.OTHER: <br /> ❑3.INSURANCE D 6.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 [:12. PROPERTY OWNER DO 3.TANK OWNER 423 <br /> VII.APPLICANT SIGNATURE <br /> Certification: I certify that the information provided ierein is true and accurate to the best of my knowledge. <br /> SIGNATURE OF APPLICANT DATE424 PHONE 11: <br /> S. � /C 3� 1(6 - 3 )o - I( S-- �_ <br /> NAME OF APPLICANT(print) TITLE OF APPLICANT 4'-7 <br /> W( C t4 i4-E L Ar L TO N C C A-c,T O►-t_ <br /> STATE UST FACILITY NUMBER(Agcncyuwonly) 428. 1998 UPGRADE CERTIFICATE NUMBER(Agencyuse oily) 42 <br /> 9 <br /> (See Data Element 1,above. <br /> UPCF Hwficrc-a(1/99)-1/2 htq)://www.uuidocs.ork Rev.02/16/00 <br />