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17RIFtFD PROGRAM CONSOLIDATFD FOR ( 6o <br /> TANKS <br /> UNDERGROUND STORAGE TANKS -FA <br /> (one page per site) Page_of <br /> TYPE OF ACTION ❑ L NEW SITE PERMIT ❑3.RENEWAL PERMIT ❑5.CHANGE OF INFORMATION ❑ 7.PERMANENTLYCLOSED SITE <br /> (Check one item only) ❑4.AMENDED PERMIT specify change local use only ❑ 8-TANK REMOVED <br /> ❑&TEMPORARY SITE CLOSURE 400 <br /> L FACILITY/SITE INFORMATION <br /> BUSINESS NAME(sameasFACHATYNAME aDaA-Douse m AS) 3 FACILITY IDM <br /> T St <br /> o S(� ' <br /> NEAREST CROSS STREET 40t FACILITY OWNER TYPE 4-LOCAL AGENCY/DISTRICT* <br /> CORPORATION ❑5.COUNTY AGENCY* <br /> BUSINESS 1.GAS STATION 3.FARM COMMERCIAL. ❑ 2-INDIVIDUAL ❑6.STATE AGENCY* <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR❑6. OTHER 403 ❑ 3.PARTNERSHIP ❑7.FEDERAL AGENCY* 402 <br /> TOTAL NUMBER OF TANKS Is facility on Indian Reservation or *If ownerof UST is a public agency:name of supervisor of dh isiiao,section or office which <br /> REMAINING AT SITE hiisdands? operates the UST(This is the contact person for the tank records.) <br /> 3 404 ❑ Yes QkNo 405 406 <br /> IL PROPERTY OWNER INFORMATION <br /> PROPERTY OWNERNAME 407 PHONE Ona <br /> re 1 <br /> ��771k, <br /> MAILING OR STREET ADDRESS t 41 <br /> Po Pjbx <br /> CITY J 410 STATE 411 ZIP CODE 412 <br /> S ac romeft40 CA lag_� <br /> PROPERTY OWNER TYPE 1.CORPORATION [12.INDIVIDUAL Ll 4.LOCAL AG1 AICY/DISTRICT 6.STATE AGENCY <br /> [13.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY 413 <br /> TIL TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> e 4- 0 08L-371 6 <br /> MAILING OR STREET ADDRESS 416 <br /> CITY a17 STATE 418 ZIP CODE 419 <br /> Sac -�v CA 9 585 I <br /> TANK OWNER TYPE W1.CORPORATION 112.INDIVIDUAL 4.LOCAL AGENCY/DISTRICT 6.STATE AGENCY 420 <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- -319 15 1 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 <br /> ❑2.GUARANTEE ❑S.LETTER OF CREDIT N.STATE FUND&CFO LETTER ❑ 99.OTHER: <br /> [13.INSURANCE ❑6.EXEMPTION ❑9.STATE FUND&CD 4n <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Chock one box to indicate which address should be used for legal nouticaaions and mailing <br /> Legal notifications and mailings will be sent to the tank owner unless box I or 2 is checked ❑ 1.FACILITY [12- PROPERTY OWNER ❑3.TANK OWNER 423 <br /> VII.APPLICANT SIGNATURE <br /> Certification-I certify that the information provided herein is trio and accurate to the best of my knowiedgc- <br /> StGNATVIY OF AP LIC NT DATE 424 1 PHONE 425 <br /> - - g t 6-396-3716 <br /> NAME OF AFOPLICANT((print) 426 TITLE OF APPLICANNT-1 427 <br /> Gee .l0.KP Of r 61�1SW1� T3GlM1I11 u� /` <br /> STATE UST FXCILITY NUMBER(For bnl use ady) 428 1998 UPGRADE CERTIFICATE NUMBER(For tont ase only) 429 <br /> UPCF(1/99 revised) 8 Formerly SWRCB Form A <br />