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Am <br />FIED PROGRAM CONSOLIDATED R RM <br />TANKS <br />UNDERGROUND STORAGE TANKS - FACILITY <br />E: <br />(one page per site) Page - of _ <br />TYPE OF ACTION ❑ I. NEW SITE PERMIT 3. RENEWAL PERMIT ❑ 5.CIIANGE OF INFORMATION ❑ TPERMANENTLY CLOSED SITE <br />(Check one item only) �4. AMENDED PERMIT Specify e local use only P Y chang y ❑ 8. TANK REMOVED <br />O 6.TEMPORARY SITE CLOSURE 400 <br />I. FACILITY / SITE INFORMATION <br />BUSINESS NAME (Sano as FACILITY NAML• or DBA -Doing nosiness As) 3 <br />hACILITY ID# <br />I <br />I <br />1 <br />NEAREST CROSS STREET 1 . 401 <br />- ' J�za :k�50�r► five. <br />-] <br />FACILITY OWNER TYPE ❑ 4. LOCAL AGENCY/DISTRICT' <br />t3 L CORPORATION ❑ 5. COUNTY AGENCY" <br />❑ 2. INDIVIDUAL ❑ 6. STATE AGENCY' <br />BUSINESS I. GAS STATION C13. FARM ❑ 5. COMMERCIAL <br />TYPE ❑ 2. DISTRIBUTOR ❑ 4. PROCESSOR ❑ 6. OTHER 403 <br />❑ 3. PARTNERSHIP ❑ 7. FEDERAL AGENCY- 402 <br />TOTAL NUMBER OF TANKS <br />Is facility on Indian Reservation or <br />*If owner of UST is a public agency: name ol'supervisor of division, section or oil -ice which <br />REMAINING AT SITE <br />trustlands? <br />operates the UST (This is the contact person for the tank records.) <br />404 <br />❑ Yes [Z' No 405 <br />406 <br />II. PROPERTY OWNER INFORMATION <br />PROPERTY OWNER NAME 407 PHONE <br />408 <br />MAILING OR STRL-ET ADDRE S <br />r 3 409 <br />CITY 410 <br />STATE 4t1 <br />ZIP CODE 412 <br />t' <br />PROPERTY OWNER'1'YPE❑ 1. CORPORATION 2. INDIVIDUAL ❑ 4. LOCAL AGENCY / DISTRICT ❑ 6. STATE AGENCY <br />❑ 3. PARTNERSHIP (:15. COUNTY AGENCY ❑ 7. FEDERAL AGENCY 413 <br />II1. TANK OWNER INFORMATION <br />TANK OWNER NAME_ 414 PHONE <br />415 <br />c�Pe 2 Cp000 <br />MAILINGORSTREET ADDRESS - <br />416 <br />CITY <br />417 STATE 418 "LII' CODE 419 <br />C <br />TANK OWNER TYPE ❑ 1. CORPORATION ❑ 2. INDIVIDUAL ❑ 4. LOCAL AGENCY / DISTRICT ❑ 6. STATE AGENCY 420 <br />3. PARTNERS}IIP ❑ 5. COUNTY AGENCY ❑ 7. FEDERAL AGENCY <br />IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br />TY (TK) HQ 44- 1 C) I 2 O $ Call (916) 322-9669 if questions arise 421 <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br />INDICATE METITOD(s) ❑ 1. SELF-INSURED ❑ 4. SURETY BOND 0,7. STATE FUND ❑ 10. LOCAL GOVT MECHANISM <br />❑ 2. GUARANTEE ❑ 5. LETTER OF CREDIT ❑ 8. STATE FUND & CFO LETTER ❑ 99. OTHER: _ _ _ • _ <br />❑ 3. INSURANCE ❑ 6. EXEMPTION ❑ 9. 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. ❑ L FACILITY ❑ 2. PROPERTY OWNER ('4 3. 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 />SIGNATURE OF APPLICANT <br />DATE 424 <br />PHONE 425 <br />NAME OF APPLICANT(print) 426 <br />TITLE OF APPLICANT 427 <br />STATE UST FACILITY NUMBER (For local use only) 4281998 <br />is <br />UPGRADE CERTIFICATE NUMBER (For local use only) 429 <br />UYUP (1/99 revised) <br />k �Ip�I������ Formerly SWRCB Form A <br />