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r� IED PROGRAM CONSOLIDATED FO + IbV00 TANKS <br /> UNDERGROUND STORAGE TANKS - FACILI 1,9f gaps <br /> (one page per site) igeof <br /> TYPE OF ACTION ❑ L NEW SITE PERMIT ❑3.RENEWAL PERMIT 95CHANGE OF INFORMATION ❑ TPERMANENTLY CLOSED SITE <br /> (Check one item only) ❑4.AMENDED PERMIT specify change local use only ❑ 8.TANK REMOVED <br /> ❑&TEMPORARY SITE CLOSURE 400 <br /> I. FACILITY/SITE INFORMATION 12,0 kx`i <br /> BUSIN SS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 FACILITY IDr9 w <br /> so I <br /> NEAREST CROSS STREET 401 FACILITY OWNER TYPE ❑4.LOCAL AGENCY/DISTRICT* <br /> P t <br /> .CORPORATION ❑5.COUNTY AGENCY* <br /> BUSINESS ❑ 1.GAS STATION ❑3.FAXM XN. 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 owner of UST is a public agency:name of supervisor of division,section or office which <br /> REMAINING AT SITE trustlands? operates the UST(This is the contact person for the tank records.) <br /> 3 404 ❑ Yes J No 405 406 <br /> H. PROPERTY OWNER INFORMATION <br /> PROP E TY OPHONE 408 <br /> '116-396%06 <br /> MAILING OR STREET ADDRESS 409 <br /> n <br /> O <br /> CITY 15002- <br /> 410 1 STATE 411 ZIP CODE 412 <br /> PROPERTY OWNER TYPE CORPORATION ❑2.INDIVIDUAL [14.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY 413 <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> 6 <br /> MAILING OR STREET ADDRESS 416 <br /> CITY 412 STATE 418 ZIP CODE 419 <br /> sacralneifo A 199s <br /> TANK OWNER TYPE ;kI.CORPORATION ❑2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 420 <br /> [:13.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.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) ❑ 1.SELF-INSURED ❑4.SURETY BOND ❑7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM <br /> ❑2.GUARANTEE ❑5.LETTER OF CREDIT>k8.STATE FUND&CFO LETTER ❑ 99.OTHER: <br /> ❑3.INSURANCE ❑6.EXEMPTION [-19.STATE FUND&CD 422 <br /> VI.LEGAL 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 ❑2. PROPERTY OWNER X.TANK OWNER 423 <br /> VII.APPLICANT SIGNATURE <br /> Certification-I certify that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNAT F A LIC DATE / 424 1 PHONE 425 <br /> 3 116-364-3797 <br /> NAME AP LICANT( rtn426 TITLE OF APPLICANT 422 <br /> _ <br /> STATE UST FACILITY NUMBER(For local use only) 428 1998 UPGRADLYCERTIFICATE NUMBER(For local use only) 429 <br /> UPCF(1/99 revised) 8 Formerly SWRCB Form A <br />