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D PROGRAM CONSOLIDATEJWWM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page per site) <br /> Page _ of _ <br /> TYPE OF ACTION r 1.NEW SITE PERMIT r 3.RENEWAL PERMIT 5.CHANGE OF INFORM T (S cify change- r T PERMANENTLY CLOSED SITE <br /> (Check one item only) r ,^W' '�J�iL. <br /> 4.AMENDED PERMIT local use only) I.� If , r B.TANK REMOVED 400 <br /> F 6.TEMPORARY SITE CLOSURE <br /> I.FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 FACILITY ID# <br /> hSC CoN M/N/' <br /> 'L ,�I FACILITY OWNER TYPE r 4. LOCAL AGENCY/DISTRICT• <br /> `� .E_ os/ ���. e -�sca.�d'1 "c�i )�� TJC1 CORPORATION I 5. COUNTY AGENCY- <br /> BUSINESSTYPE -Jk1 GAS STATION r 3.FARM r 5.COMMERCIAL r 2. INDIVIDUAL <br /> r 6. STATE AGENCY' <br /> 2.DISTRIBUTOR r 4.PROCESSOR r 6.OTHER r 3. PARTNERSHIP r <br /> r 7. FEDERAL AGENCY' 402 <br /> 403 <br /> TOTAL NUMBER OF TANKS Is 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 r Yes ]�No 405 406 <br /> II.PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 /T�/0 l A/9 �n / A PHONE�- 408 <br /> MAILING OR STREET ADDRESS 409V� <br /> / -�Lt7- l3�/<IW- �}G� # <br /> CITY 410 STATE 411 ZIP CODE 412 <br /> PROPERTY OWNER TYPE r 2. INDIVIDUAL r 4. LOCAL AGENCY/DISTRICT r 6. STATE AGENCY 413 <br /> I CORPORATION <br /> r 3. PARTNERSHIP r 5. COUNTY AGENCY r 7. FEDERAL AGENCY <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 ( �Y PHONE 415 <br /> MAILING OR STREET ADDRESS 416 _ <br /> f ro � 7 !'- o,S( "(' J E- <br /> y�f <br /> CITY 417 STATE 418 ZIP CODE 419 <br /> Cs(f,�La fv o 4 1g 5-3 2 0 <br /> TANK OWNER TYPE r 2. INDIVIDUAL F 4. LOCAL AGENCY/DISTRICT I' 6. STATE AGENCY 420 <br /> F?T CORPORATION F 3. PARTNERSHIP IF 5. COUNTY AGENCY IF 7. FEDERAL AGENCY <br /> TY(TK)HQ 4 4 Call(916)322-9669 if questions arise 421 <br /> INDICATE METHOD(S) r 1. SELF-INSURED r 4. SURETY BOND r 7. STATE FUND r 10. LOCAL GOV=T MECHANISM <br /> F 2. GUARANTEE r 5. LETTER OF CREDIT WB. STATE FUND&CFO LETTER r 99. OTHER: <br /> F 3. INSURANCE r 6. EXEMPTION r 9. STATE FUND 8 CD 422 <br /> Check one box to indicate which address should be used for legal notifications and mailing. r>14. FACILITY r 2. PROPERTY OWNER IF 3. TANK OWNER 423 <br /> Legal notifications and mailinas will be sent to the tank owner unless box 1 or 2 is checked. <br /> VII A PPI ICA N1 SIGNATI IRE <br /> Certification: I certify that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNATURE OF APPLICANT DATE &1- O / 424 1 PHO�r E 425 <br /> �,loS- <br /> NAME OF APPLICANT(print) n V 426 TITLE OF APPLICANT DL, VI,�V 427 <br /> STATE UST FACILITY NUMBER/(Forloca/use only) 428 1998 UPGRADE CERTIFICATE NUMBER(Forlocal use only) 429 <br /> Ot �I1s1ok <br /> UPCF(1/99 revised) 5 Formerly SWRCB Form A <br />