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UED PROGRAM CONSOLIDATED F M <br /> TANKS <br /> / v UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page per site) <br /> Page _ of _ <br /> TYPE OF ACTION F 1.NEW SITE PERMIT F 3.RENEWAL PERMIT r 5.CHANGE OF INFORMATION(Specify change- F 7.PERMANENTLY CLOSED SITE <br /> (Check one item only) <br /> r 4 AMENDED PERMIT local use only) r B.TANK REMOVED 400 <br /> F 6.TEMPORARY SITE CLOSURE <br /> I.FACILITY!SITE INFORMATION <br /> BUSINESS NAME(Same as FACILITY NAME or 08A-Doing Business As) 3 FACILITY ID# <br /> A9,U_>0CCzo 11111 11, 0 6 <br /> NEAREST CROSS STREET 401 FACILITY OWNER TYPE F 4. LOCAL AGENCY/DISTRICT- <br /> 1-+// JEF- Q�_m I F 1. CORPORATION F 5. COUNTY AGENCY' <br /> BUSINESS TYPE 1.GAS STATION r 3.FARM r 5.COMMERCIAL r 2. INDIVIDUAL <br /> F 6. STATE AGENCY' <br /> F 2.DISTRIBUTOR r 4 PROCESSOR F 6.OTHER r 3. PARTNERSHIP F 7. FEDERAL AGENCY' 402 <br /> 403 <br /> TOTAL NUMBER OF TANKSIs facility on Indian Reservation or 'If owner of UST is a public agency:name of supervisor of <br /> REMAINING AT SITE trustlands? division.section or office which operates the UST. <br /> (This is the contact person for the tank records.) <br /> 404 3 F Yes No 405 406 <br /> II.PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408 <br /> 'Prolti 6�b -5�L b <br /> MAILING OR STREET ADDRESS 409 <br /> "Po x 60 <br /> CITY 410 STATE 411 ZIP CODE 412 <br /> a2�5�� C�► 900 �60� <br /> PROPERTY OWNER TYP r 2. INDIVIDUAL r 4. LOCAL AGENCY/DISTRICT r 6. STATE AGENCY 413 <br /> 1. CORPORATION F 3. PARTNERSHIP r 5. COUNTY AGENCY F 7. FEDERAL AGENCY <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> MAILING OR STREET ADDRESS 416 <br /> Fb OX 6d <br /> CITY 417 STATE 418 ZIP CODE 419 <br /> 142Ta-s�A CA 19070z-/,<z)%6 <br /> TANK OWNER TYPE r 2. INDIVIDUAL r 4. LOCAL AGENCY/DISTRICT r 6. STATE AGENCY 420 <br /> t. CORPORATION [ 3. PARTNERSHIP F 5. COUNTY AGENCY r 7 FEDERAL AGENCY <br /> TY(TK) HO 1 4 1 4 j()j0j0jV Rq'�'Rr"'g:ll:nI 6 Call(916)322-9669 if questions arise 421 <br /> r <br /> 1N01CATE METHOD(S) INF. 1. SELF-INSURED r 4. SURETY BOND r 7. STATE FUND I' 10. LOCAL GOV=T MECHANISM <br /> r 2. GUARANTEE r 5. LETTER OF CREDIT F 8. STATE FUND&CFO LETTER r 99. OTHER: <br /> F 3. INSURANCE r 6. EXEMPTION r 9. STATE FUND 8 CO 422 <br /> Check one <br /> x,0 indicate which address should be used for legal notifications and mailing. F 1. FACILITY 2. PROPERTY OWNER r 3. TANK OWNER 423 <br /> Le al notifications and mailin swill be sent to the tank owner unless box 1 or 2 is checked. <br /> Certification: I certify that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNATURE OF APPLICANT DATE 424 PHONE 425 <br /> NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 427 <br /> STATE UST FACILITY NUMBER(For local use only) 428 19911 UPGRADE CERTIFICATE NUMBER(For local use only) 429 <br />