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FIFD PROGRAM CONSOLFDATFD FOR <br /> TANKS <br /> UNDERGROLWD SE TANKS -FACIUTY <br /> (one page per site) Page-of- <br /> TYPE OF ACTION j5 1.NEW SITE PERMIT 0 3.RENEWAL PERMIT' W.CUNGE OF INFORMATION 0 TPERMANENTLY CLOSED SITE <br /> (Check one item only) 0 4.AMENDED PERMIT specify change local on only- 0 8.TANK REMOVED <br /> 0&TEMPORARY SITE CLOSURE 400 <br /> L FACILITY/SITE INFORMATION <br /> " <br /> T <br /> BUSINESS E( FACELM N DRA Doing Rusincss FACILITY 11 <br /> - N Xas,a ,+ �746n ,- AS) 3 I - <br /> NEAREST CROSS STREET 401 F?TILITY OWNER TYPE 4.LOCALAGENCY/DISTRICT* <br /> Mi.CORPORATION ❑5.COUNTY AGENCY* <br /> BUSINESS 0 1.GAS STATION [13.FARM COMME 0 2.INDIVIDUAL 0 6.STATE AGENCY* <br /> TYPE 0 2.DISTRIBUTOR 0 4.PROCESSOR 0 6. OTHER 4o3 0 3.PARTNERSHIP 0 7.FEDERAL AGENCY* 402 <br /> TOTAL NUMBER OF TANKS Is facility on Indian Reservation or *11'awner of UST is a public agency.name ofsupervisor of division,section or office which <br /> REMAINING AT SITE trusdands? operates the UST(This is the contact pmon for the tank ) <br /> 404 0 Yes No 406 1 4% <br /> 11. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 1 PHONE 409 <br /> 11 q 1 37 <br /> tl\, 1-e i6er-f �o- nr, <br /> MAILING OR ST ET ADDRESS 409 <br /> CITY 410 1 STATE 411 ZIP CODE 412 <br /> PROPERTY OWNER TYPE JN.CORPORATION 2.INDIVIDUAL U 4.LOCAL AGENCY/DISTRICT AGENCY <br /> 0 3.PARTNERSHIP 0 5.COUNTY AGENCY 0 7.FEDERAL AGENCY 413_ <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 1 PHONE -7 415 <br /> Ll <br /> MAILING ORITEI'ADDRESS 416 <br /> X I <br /> CITY 417 1 STATE(A4ts ZIP CODE 40 <br /> TANK OWNER TYPE <br /> ,1.CORPORATION E]2.INDIVIDUAL U 4.LOCA 6.STATE AGENCY 420 <br /> 0 3.PARTNERSHIP 0 5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(M W 44- Call(916)322-9669 if questions arise 421 <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) 0 1.SELF-INSURED 0 4.SURETY BOND 0 7.STATE FUND 0 10.LOCAL GOVT MECHANISM <br /> 0 2.GUARANTEE [15.LETTER OF CREDrr)!%.STATE FUND&CFO LETTER 0 99.OTHER: <br /> 0 3.INSURANCE [16.EXEMPTION 0 9.STATE FUND&CD 422 <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one box to mmilicate which add=shouk!be used for legal notificatum and mailing. <br /> Legal notifications and mailings will be scot to die tank owner unless box I ort is chockcd. El 1.FACILITY 0 2. PROPERTY OWNER TANK OWNER 423 <br /> VII.APPLICANT SIGNATURE <br /> Cectification-I certify that the infannauna provided herein is true and accumate to the best army knowledge. <br /> Sl TURF OE APPLICANT DATE PHONE 425 <br /> -X U-�t <br /> NAMMF APPLICANT(print� 426 TITLE OF APPLICANT 427 <br /> .2eQf <br /> STATE UST FA CR ITY NI TMBER(Fm hxmi use o*) 428 1998 UPGRADE CERTIFICATE NUMBER(For Wcat use only) 429 <br /> UPCF(1/99 revised) 8 Formerly SWRCB Form A <br />