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ICn 00Afl-_DA11A f%^k1Qn1 InATCn CAD <br /> ' � TANKS <br /> W UNDERGROUND STORAGE TANKS - FACILITY <br /> �� �, Q (one page per site) Page of_ <br /> 1 � , <br /> TYPE OF ACTION ❑ 1.NEW SITE PERMIT ❑3.RENEWAL PERMIT ❑5.CHANGE OF INFORMATION ❑ TPERMANENTLY CLOSED SITE <br /> (Check one item only) ®4.AMENDED PERMIT specify change local use only ❑ 8.TANK REMOVED ►j <br /> ❑63EMPORARY SITE CLOSURE 1 400 <br /> I. FACILITY/SITI=INFORMATION <br /> BUSINESS NAME(Same as FACILITY NAMEorDBA-Doin�B '' 3 FACILI#T°Y'ID# <br /> NELLA Oil Company#427111. <br /> NEAREST CROSS STREET 401 FACILITY OWNER TYPE [14.LOCAL GENCY/DISTRICT* <br /> Report Ave ❑ 1.CORPORATION [:15.COUNTY AGENCY* <br /> BUSINESS ® 1.GAS STATION ❑3.FARM ❑5, COMMERCIAL ❑ 2.INDIVIDUAL [:16.STATE AGENCY* <br /> TYPE ❑2.DISTRIBUTOR [14.PROCESSOR❑6. OTHER 403 ® 3.PARTNERSHIP ❑7.FEDERAL AGENCY* 402 <br /> TOTAL NUMBER OF TANKS Is facility on Indian Reservation or *If owner of UST is a public agency:name of supervisor of division,section or office <br /> REMAINING AT SITE trustlands? which operates the UST(This is the contact person for the tank records.) <br /> 3 404 ❑ Yes ❑ No 405 406 <br /> 11 PR OPERTY 6WNER INFCI?iMAT!ON' <br /> PROPERTY OWNER NAME 407 PHONE 408 <br /> Quentin Kirsch 713 744 4152 <br /> MAILING OR STREET ADDRESS 409 <br /> 1 190 Amber Way <br /> CITY 410 STATE 411 ZIP CODE 412 <br /> Hanford I CA 93230 <br /> PROPERTY OWNER TYPE ❑ 1.CORPORATION ®2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL 413 <br /> IIh 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 /> 2349 Rickenbacker Way <br /> CITY 417 STATE ata ZIP CODE 419 <br /> Auburn CA 95602 <br /> TANK OWNER TYPE ❑ 1.CORPORATION ❑2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 420 <br /> ®3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> IV.BOARD OF;EG>€IIALI TI N UST�4R/�GE FEE ACCQUt4T NUM �- <br /> TY TK HQ 44- 1 0 1 2 19 1 11 `)- Call 916 322-9669 if uestions arise 421 <br /> V. PETROLEUM UST:FINANCIAL RESPONSIBILITY <br /> INDICATE ❑ 1.SELF-INSURED ❑4.SURETY BOND [:17.STATE FUND ❑ 10.LOCAL GOVT MECHANISM <br /> METHOD(s) ❑2.GUARANTEE ❑5.LETTER OF CREDIT 710 8.STATE FUND&CFO LETTER ❑ 99.OTHER: <br /> ❑3.INSURANCE ❑6.EXEMPTION ❑ 9.STATE FUND&CD 422 <br /> 0A0AL=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 02. PROPERTY OWNER ❑3.TANK 423 <br /> OWNER <br /> NII.APPLICANTSIGNATURE . <br /> Certification-I certify that the informati provided herei is true and accurate to the best of my knowledge. <br /> =PIPLICANT <br /> OF PPLICANT DATE 424 PHONE 425 <br /> 1k - 1/25/05 530-885-0401(print) 426 :TITLE.OF APPLICANT 427 <br /> J Barbara Wozniak Environmental Coordinator <br /> STATE UST FACILITY NUMBER(For local use only) 428 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 <br /> UPCF(1/99 revised) Formerly SWRCB Form A <br />