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71 t009"to io S`[1 C i A <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACIDLm <br /> am= (one page site) Page_INKS <br /> TYPE OF ACTION ❑ 1.NEW SITE 3.RENEWAL PERMIT 0 ICHANCE OF TION ❑ IFERMANENTLY CLOSED SITE <br /> (check one item only) ❑4.AMENDED PERMIT specify change local use only 0 $.TANK O <br /> ❑6.TEhIPORARY SITE CLOSURE 490 <br /> I. FACILITY/SITE INFORMATION <br /> BUSINESS N (same as FAciury NAms of DBA- AS) 3 FACII, <br /> Circle 2705448 ' <br /> NEAREST CROSS STREET 401 FACILITY OW 4 1 Al GENCY/DISTRICT* <br /> Kelly Dr. 0 1.CORPORATION ❑5.COUNTY AGENCY* <br /> BUSINESS D9 1.GAS STATION 0 3.FARM 0 5. CO RCIAL ❑ 2.INDIVIDUAL ❑6.STATE AGENCY* <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR❑6. OTHER 403 ❑ 3.PARTNERSHIP ❑7.FEDERAL AGENCY* 402 <br /> TOTAL NUMBER OF TANKS Is facility on Indian Regervation or "If owner ofUST is a public agency.natim of superAwr of division,section or office which <br /> REMAINING AT SITE lands? operates the UST contact person forthe took records.) <br /> 3 404 0 Yes N No 405 46 <br /> JIL PROPERTY <br /> PROPERTY OWNER NAME 407 pHONE 40 <br /> Kayo Oil 916-558-7612 <br /> MAILING OR STREET ADDRESS 409 <br /> 76 Broadway <br /> CITYala STAB 411 ZIP CODE 412 <br /> Sa CA 95818 <br /> PROPERTY OWNER TYPE I.CORPORATION 2.INDIVIDUAL 4.LOCAL AGENCY/DISTRICT 6.STATE AGENCY <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY 0 7.FEDERAL AGENCY 413 <br /> III.TANK OWNER INFORMATION <br /> TANK OVMER NAME 414 1 PHO 415 <br /> Conoco PhilyjC 916-558-7612 <br /> MAILING OR STREET ADDRESS 416 <br /> 76 Broadway <br /> CITY 417 STATE 418 ZIP CODE 419 <br /> Sacramento I CA 95818 <br /> TANKOVINERTYPE 1.CORPORATION 0 2.INDIVIDUAL 0 4.LOCAL AGENCY/DISTRICT 6.STATE AGENCY 420 <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> IV.BOARD F EQUALIZATION UST STORAGE FEE ACCOUNT <br /> Ty Q - 1 4 1 1 19-1-9-1-8 CaH(916)322-9669 if questions arise 421 <br /> V.PETROLEUM UST FINANCIAL RESPONSEBILYff <br /> INDICATE METHOD(s) 0 1.SELF-INSURED ❑4.SURETY BOND ❑7.STATE FUND ❑10.LOCAL GOVT MECHANISM <br /> ❑2.GUARANTEE ❑5.LETTER OF CREDIT ❑8.STATE FUND&CFO LETTER ❑ 99.0 R: <br /> ®3.INSURANCE ❑6.EXEMPTION ❑9.STATE FUND&CD 422 <br /> VL LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one box to indicate which address should be used for legal notifivations and mailing. <br /> Legal noblioations and mailings will be sent to the tank owner unloss bm I or 2 ffi dhooked. ❑ L FAC ❑2.PROPERTY OWNER CM 3.TANK OWNER 423 <br /> VIEL APPLICANT SIGNATURE <br /> Certification-I certify that the i4annation provided is true and accurate to the bad ofmy <br /> SIG AWRE OF APPLICANT DATE 424PHONE 425 <br /> 11/4/03 (916)635-2444 <br /> WAmE OF AppucOF APPLICANT 427 <br /> LC.Dy Agent for Owner <br /> STATE UST FACI ER(For lei we only) 428 1998 UPGRADE CERTIFICATE NUMBER(For loc a nse only) <br /> T TPr,F(1/99 ) 171 FormerIvRUM Formerlyr.1R Fnrm A <br />