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UNIFIED PROGRAM CONSOLIDATED FORMTINKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (one gage per site) Page_ <br /> I TY ....,E Or ACTIC)V (] NEJV SI'rF HERMIT (]:t.RENEWAL PERivh,7 5-CHANGE OF INFORMATION C TPERMANENTLY CLOSED SITE <br /> (C eck one item or v) 0` <br /> t.AMENI�EC PERMIT specify change local use Only .,_�_�_�._ [ 8.TANK REMOVED <br /> E]6 TEMPORARY SITE CLOSURE 400 <br /> LUrI. FACILITY I SITE INFORMATION <br /> h+" <br /> SI�NESS 4AP'.dE �a v as F c.l_I iY E vE 4. Dutng 3u",n 5 ., Ff�',ILITY 10# <br /> NELLA Oil C empanv #427 ._ 1_._.__. _ <br /> FACILI"rY <br /> N OWNER TYPE ❑4. LOCAL GENCY/DISTRICT" <br /> REST CROSS STREET BEET <br /> 0 Ave �..-. -® ..__.�.__� ❑ 1.CORPORATION ❑5. COUNTY AGENCY" <br /> BUSINESS 1 GAS STATIQN 3.rARPA I� � VOM v E CW AL ® 2. INDIVIDUAL ❑6. STATE AGENCY- <br /> BL <br /> F RAL AGENCY" 4 <br /> TYPE Cl�- D!STRI6 JTC�R 0 4 PROCESSOR❑6. OTHEH act i ® 3-PARTNERSHIP ❑ EDE 02 <br /> ) `-- -x— p f - -w—^y .name of supervisor of d <br /> i} T TAL PIU FF }F 7ANI S Is facllik'on Indian fZa�ervatan or If ewr.er or UST-s a public agent ivik r section or office <br /> REMAINING AT SITE trustlands'? which operates the UST{Thi>is the contact person for the Sank records.) <br /> 3 404 ❑ Yes I❑ No do <br /> - -- - <br /> 111. PROPERTY OWNEWINFQRMATION <br /> 408 <br /> tt n Kirsc tCR id.? tE <br /> - 713 744 4152 <br /> uenI MAILING OR STREET"ADDRESS 409 <br /> 190 Amber Way <br /> ___-- <br /> zP ® E{Y — r 412 <br /> HanfordCA -. 93230 i <br /> PROPERTY 0N:vER`TYPE L�' CORPORATION P] 2.',NDiV;CUA_ ❑4. LOCAL AGENCY/DISTRICT ® 6.STATE AGENCY <br /> ] 3 PAR.TNFRSHIP ®5. COUNTY AGENCY ❑7. FEDERAL 413 <br /> III.TANK OWNER I NFQR ATION <br /> TANK QWNER NNP IE 414� PHQNE 415 i <br /> NELLA Oil Company -___-- X30 885 oaol <br /> I - <br /> MAILING OIC S kt:7ET ADDRESS 416 <br /> 2349 R,ChenbaCk: r V\Ia}' <br /> --�` 5T'ATE ;a ZIP CODE 419 1 <br /> AuburnC- <br /> C�'__a_ 5602 <br /> TANK QVANCR YPE --- ] '. CORPQR�4T10N 2 !NL [�4 LOCAL AGENCY/D1STRlCT ❑6. STATE AGENCY 420 <br /> Z _3 PARTNERSHIP ❑5.COUNTY AGENCY ❑ 7. FEDERALAGENCY <br /> IV. BOARD OF',EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER` <br /> TY (TK) HO 44 �- c g LgT Call (916) 322-9669 If questions arise — 421 <br /> V.',PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE ❑ 1 SELF-INSURED C]4 SURETY BOND ❑7.STATE FUND [110,LOCAL GOVT MECHANISM <br /> METHOD(s) ❑ 2 GUARANTEE [] 5 LETT Erb OF CREDIT L7J 8.STATE FUND&CFO LE"T-TER ❑ 99.OTHER: <br /> k Q 3. INSURANCE []b EXEMPTION ❑9. STATE FUND&CD 422 <br /> VI:LEGAL NOTIFICATION A .6 AILING ADDRESS <br /> Ct1ECk one t.ox tato ndkoatp wrich aadcest stiouid Le used for legaa notifications,c� d,railing. <br /> ' Legal r cnfiCanof 4 a ic,Trail l qs wll: e sant L,)the:ark awne u:;'es.,oox 1 or� 1_ct,ecked. ❑ 1,FACILITY ®2 PROPERTY OWNER ❑3,TANK 423 ' <br /> OWNER, <br /> 71 <br /> VII. APPLICANT T SIGNATU. E <br /> cenificaticn . c.. J y th,I,,he m*,,a I"pl'OVIdCd 11E9ri?In IS ltde Ona 3CCUf8.P.,...h2 Desi Of my kno'v ec"" <br /> SIGNATURE (?P P�l N - DATE - -a a ( PHONE -_ 425 <br /> •�" a+ ' 530-885-0401 <br /> NAME ANI �Ott) � TITLE OF APPLICANT 427 a <br /> laCk _4 Director of Enaineerinc <br /> S',G1T Fc cca,�seony', 429 <br /> i <br /> i', <br />