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r <br /> IED PROGRAM CONSOLIDATED F <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (One page per site) Page_of <br /> TYPE OF ACTION ❑1.NEW PERMIT ❑3.RENEWAL PERMIT ®5.CHANGE OF INFORMATION ❑7.PERMANENTLY CLOSED SITE 400 <br /> (Check one item only) ❑4.AMENDED PERMIT (Specify change) ❑8.TANK REMOVED <br /> ❑6.TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3. FACILITY <br /> Nella Oil#427 ID# <br /> 71 <br /> NEAREST CROSS STREET 401. FACILITY OWNER TYPE E3 4.LOCAL AGENCY/DISTRICT* 402. <br /> Report Ave. ❑ 1.CORPORATION ❑5.COUNTY AGENCY* <br /> BUSINESS ED 1.GAS STATION 3.FARM 5.COMMERCIAL 403. ❑2.INDIVIDUAL ❑6.STATE AGENCY* <br /> TYPE [12.DISTRIBUTOR [:14.PROCESSOR ❑6.OTHER ®3.PARTNERSHIP ❑7.FEDERAL AGENCY* <br /> TOTAL NUMBER OF TANKS 404. Is 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. (This is the contact person for the tank records.) <br /> 3 ❑Yes ONO <br /> IL PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 408 <br /> Quentin Kirsch 713-744-4152 <br /> MAILING OR STREET ADDRESS 409 <br /> 190 Amber Way <br /> CITY 410. STATE 411. ZIP CODE 412. <br /> Hanford I CA 95602 <br /> PROPERTY OWNER TYPE 1.CORPORATION 2.INDIVIDUAL 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 415. <br /> Nella Oil Company,LLC 530-885-0401 <br /> MAILING OR STREET ADDRESS 416, <br /> 2360 Lindbergh Street <br /> CITY 417. 1 STATE 418. ZIP CODE 419 <br /> Auburn CA 95602 <br /> TANK OWNER TYPE 1.CORPORATION 2.INDIVIDUAL Lj 4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 420. <br /> ®3.PARTNERSHIP ❑5.COUNTY AGENCY [:17.FEDERAL AGENCY <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 1 1 1 1 1 1 F Call(916)322-9669 if questions arise 421 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ❑ 1.SELF-INSURED ❑4.SURETY BOND ❑7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM 4„ <br /> ❑2.GUARANTEE ❑5.LETTER OF CREDIT ®8.STATE FUND&CFO LETTER ❑99.OTHER: <br /> ❑3.INSURANCE ❑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 1 or 2 is checked. ❑ 1.FACILITY ❑2. PROPERTY OWNER ®3.TANK OWNER 423. <br /> VII. APPLICANT SIGNATURE <br /> Certification: I certify that the information provided herein is true and accurate to the best of my knowledge. <br /> SIG TURE OF APPLICANT DATE 424, PHONE 425 <br /> .7 . <br /> 12/15/06 (530) 885-0401 <br /> N"XME OF APPLICANT(print) 426. TITLE OF APPLICANT 427 <br /> Amanda Massey Environmental Manager <br /> STATE UST FACILITY NUMBER(Agency use only) 428. 1998 UPGRADE CERTIFICATE NUMBER(Agency use only) 429 <br /> (See Data Element 1,above. <br /> UPCF Hwfwrc-a(1/99)-1/2 http://www.unidocs.org Rev.02/16/00 <br />