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AL <br /> ED PROGRAM CONSOLIDATED FO at`� <br /> TANKS ,l <br /> UNDERGROUND STORAGE TANKS - FACILIGTYge per site) Page_of <br /> 400. <br /> TYPE OF ACTION ❑1.NEW PERMIT ❑3.RENEWAL PERMIT �5.CHANGE OF INFORMATION <br /> [17..TANK REMOVED LOSED SITE <br /> (Check one item only) ❑4.AMENDED PERMIT (Specify change) <br /> ❑6.TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3. FACILITYr <br /> D O O r I• i1 t. <br /> MAkDTeC-A �P�Lvt2� <br /> IDS `T O' <br /> NEAREST CROSS STREET sot. WNER TYPE 4.LOCAL AGENCY/DISTRICT* sot. <br /> RATION ❑5.COUNTY AGENCY* <br /> BUSINESS 1.GAS STATION 3.FARM ❑5.COMMERCIAL 403. DUAL ❑6.STATE AGENCY* <br /> TYPE [12.DISTRIBUTOR ❑4.PROCESSOR [16.OTHER [13.PARTNERSHIP ❑7.FEDERAL AGENCY* <br /> 405. *If owver of UST is a public agency:name of supervisor of division,section or 406. <br /> TOTAL NUMBER OF TANKS 404. Is facility Indian Reservation office which operates the UST. (This is the contact person for the tank records.) <br /> REMAINING AT SITE 3 or trust landd s? <br /> ❑Yes [&No <br /> IL PROPERTY OWNER INFORMATION <br /> 407. PHONE 40s. <br /> FROPERTY OWNER NAME <br /> A Ern K N 0%Z asrA►-�r 0 6�� OatZ LILING OR STREET ADDRESSSTATE 411. ZIP CODEs12-TY L' A- <br /> �ti��K <br /> PROPERTY OWNER TYPE ORPORATION 2.INDIVIDUAL 4.LOCAL AGENCY(DISTRICT ❑6.STATE AGENCY :413, <br /> ❑3.PARTNERSHIP [15.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> III.TANK OWNER INFORMATION <br /> 41a. PHONE <br /> TANK OWNER NAME i15 <br /> _ ��Z 1 L� S _�'Z� <br /> PA IZ-/,k A IZ J 416. <br /> MAILING OR STREET ADDRESS Z� <br /> » U �ls-C�� j(V,-LL 1 <br /> 417 TLJ <br /> als. ZIP CODE 411 <br /> CITY { <br /> LA::$ N JT C- <br /> TANK <br /> TANK OWNER TYPE 1.CORPORATION 2.INDIVIDUALLOCAL AGENCY/DISTRICT 0 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- Call 916 322-9669 if questions arise 421. <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) [11.SELF-INSURED ❑4.SURETY BOND ❑7.STATE FUND ❑10.LOCAL GOVT MECHANISM 422 <br /> 3.INSURANCE 0 5.LETTER OF❑6.EXEMPTION CREDIT a s.STATE FUND&CFO❑9.STATE FUND&CD LETTER ❑99.OTHER: <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one box to indicate which address should be used for legal notifications and mailing. 423- <br /> Legal <br /> 23 <br /> Legal notifications and mailings will be sent to the tank owner unless box 1 or 2 is checked ,K 1.FACILITY ❑2. PROPERTY OWNER ❑3.TANK OWNER <br /> VII.APPLICANT SIGNATURE <br /> Certification: I certify that the information provided herein is true and accurate to the best of my knowledge_ 425 <br /> DATE aza. PHONE <br /> SIGNAT E OF APP (CANT <br /> 427. <br /> NAME OF APPLICANT(print) 426 TITLE OF APPLICANT <br /> STATE UST FACILITY NUMBER(Agency use only) <br /> 428. 1999 UPGRADE CERTIFICATE NUMBER(Agency use only) e29 <br /> (See Data Element 1,above. <br /> 4 htt //www.unidecs.org Rev.02/16/00 <br /> UPCF Hwfwrc-a(1/99)-1/2 P <br />