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• I <br /> D PROGRAM CONSOLIDATED FORM ' <br /> TANKS <br /> UNDERGROUND STORAGE TANKS = FACILITY <br /> (One page per site) Page_of <br /> TYPE OF ACTION NEW PERMIT ❑3.RENEWAL PERMIT ❑5.CHANGE OF INFORMATION ❑7.PERMANENTLY CLOSED SITE 400• <br /> (Check one item only) v` ❑4.AMENDED PERM 17(Spoeify etunge) ❑8.TANK REMOVED " <br /> (]6.'TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION <br /> By,INEESS NAME(saw>.F LITY NAME or DBA-Doing Business As) ), FACILITY <br /> NEAREST CROSS STREET I 4oi. FACILITY OWNER TYPE 4.LOCAL�AMrNIIIIIIICT' 402• <br /> ❑ I.CORPORATION ❑5.COUNTY AGENCY' <br /> BUSINESS:LJ 1-GAS'STATION Lj 3.FARM COMMERCIAL 403. ;41IND(VIDUAL 0 6.STATE AGENCY' <br /> TYPE ❑2.DISTRIBUTOR [14.PROCESSOR Ej 6.OTHER - ❑3.PARTNERSHIP [17.FEDERAL AGENCY- <br /> TOTAL NUMBER OF TANKS iO4• Is faeiiity on Indian-Reservation 405. 'If owner of UST(s a public agency; name of supervisor of division.section or._ 406. <br /> PLEMAININ AT SITE or trust lands? office which operates the UST. (This is the contact person for the tank records:) <br /> 7is ❑Yes 0- <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407• PHONE 400" <br /> 429 r//.11 o i:z_ <br /> MAILING OR STREET ADDRESS <br /> CITY 5�Q���� Oto, STATE 411• ZIP CODE <br /> PROPERTY OWNER TYPE El 1.CORPORATION INDIVIDUAL r34.LOCAL AGENCY/DISTRICT U 6.STATE AGENCY ». <br /> ❑3.PARTNERSHIP .0.5.COUNTY.AGENCY ❑7.FEDERAL AGENCY <br /> M.TANK ONV,NER INFORMATION <br /> TANK OWNER NAME 4u, PHONE <br /> MAILING OR STREET-ADDRESS 4 i 6 <br /> ,3.� C 4%� <br /> CITY � 4t7. STATE nn..1!70�_5 <br /> C101101 P, 4ty, <br /> TANK OWNER TYPE 1.CORPORATION INDIVIDUAL 4.LOCAL AGENCY/DISTRICT 0 6.STATE AGENCY 420, <br />�` • ❑3.PARTNERSHIP 0 3.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY TK HQ 44- Call. 91"6 322-9669 if questions.arise at. <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ❑I.SELF-INSURED 0 4.SURETY BOND ❑7.STATE FUND ❑ 10.LOCAL GOVT MECHA>iI t <br /> ❑2.GUARANTEE 17 5.LETTER OF"CREDIT ❑L STATE FUND&CFO LETTER ❑99.OTHER. 422' <br /> E 3.INSURANCE "❑6.EXEMPTION i'9.STATE FUND"R CD <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one boa to indicate which address should be used for legal notifrcatiom rad m alittg. <br /> Legal notifications and mailings will be sent to the tank owner unless box I ort is checked. 0 I.FACILITY ❑2. PROPERTY OWNER04!(3.TANK OWNER - 427. <br /> VII.APPLICANT SIGNATURE <br /> Certification: I urofy that the information prbvfd)here in 5Perug and accurate to the best of my knowledge. <br /> SIGNATURE OF APPLICANT �' DATE' J 424. <br /> PHONE,- 42$. <br /> NAME OF APPL ANT nt) I 426• TITLE OF APPLICANT 427, <br /> STATE UST FACILITY NUMBER(Aleney me only) 421• 1998 UPGRADE CERTIFICATE NUMBER(Agtncy.onhl 429• <br /> (See Data Elernent I,above. <br /> UPCF Hwfwre-a(1199)-1R httpJhrww.unidocs.org Rev.02/16/00 <br />