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D PROGRAM CONSOLIDATED F041 TANKS UNDERGROUND STORAGE TANKS - FACILITY (one page per site) Page of TYPE OF ACTION 1.NEW SITE PERMIT ❑3.RENEWAL PERMIT ❑5.CHANGE OF INFORMATION ❑ TPERMANENTLY CLOSED SI (Check one item only) ❑4.AMENDED PERMIT specify change local use only ❑ 8.TANK REMOV ❑6.TEMPORARY SITE CLOSURE �� o I. FACILITY / SITE INFORMATION BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 FACILITY ID# ✓ 0 , - - • /� 401 FACILITY OWNER TYPE ❑4.LOCAL GENCY/DISTRICT* NE� CMOS TI G QA v/J . /�/�t OU ❑ 1.CORPORATION ❑5.COUNTY AGENCY* BUSINESS u 1.GAS STATION ❑3.FARM "/❑55. COMMERCIAL�MER`C/IAL ❑ 2.INDIVIDUAL ❑6.STATE AGENCY* TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR❑6. OTHER 403 ❑ 3.PARTNERSHIP ❑7.FEDERAL AGENCY* 402 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 REMAINING AT ITE trustlands? operates the UST(This is the contact person for the tank records.) 404 ❑ Yes J� No 405 406 II. PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407 P ONE 408 �I 1d -It aC MAILING OR STREET ADDRESS 409 CITY 410 STATE 411 ZIP CODE 412 5 PROPERTY OWNER TYPE ❑ 1.CORPORATION ❑2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY ❑3.PARTNERSHIP [15.COUNTY AGENCY ❑7.FEDERAL AGENCY 413 III. TANK OWNER INFORMATION TANK OWNER NAME 414 PHONE 415 tf� MAILING OR STREET ADDRESS alb CITY 417 STATE 418 ZIP CODE 419 TANK OWNER TYPE ❑ 1.CORPORATION ❑2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 420 ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY(TK)HQ 44- 1 1 1 1 1 1 Call(916)322-9669 if questions arise 421 V. PETROLEUM UST FINANCIAL RESPONSIBILITY INDICATE METHOD(s) ❑ 1.SELF-INSURED ❑4.SURETY BOND ❑7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM ❑2.GUARANTEE ❑5.LETTER OF CREDITSTATE FUND&CFO LETTER ❑ 99.OTHER: L]3.INSURANCE [16.EXEMPTION 9.STATE FUND&CD 422 s VI. LEG*NOTIFICATION AND MAILING ADDRESS Check one box to indicate which address should be used for legal notifications and mailing. Legal notifications and mailings will be sent to the tank owner unless box 1 or 2 is checked. ❑ 1.FACILITY k2. PROPERTY OWNER ❑3.TANK OWNER 423 VII. APPLICANT SIGNATURE Certification-I certify that the information provided herein is true and accurate to the best of my knowledge. SIGNA E OF A _ICANT DATE 424 PHONE 421 �j Oct 16373 ;Vd AME OF APPLICANT(print) 426 TITLE OrF APPILICANT 427 S ATE UST FACILITY NUMBER(For local use only) 428 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 UPCF(1/99 revised) O V 171 C�1 V `�� Formerly SWRCB Form A