BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

SD PROGRAM CONSOLIDATED FORM II aI Pit#:PRO232014 FAC#:FA0003824 UNDERGROUND STORAGE TANKS -FACILITY( 1 q �O (one Page per site) TYPE OF ACTION ❑ L NEW SITE PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENTLY CLOSED SITE (Check one item only) ❑4.AMENDED PERMIT ❑ S.TANK REMOVED ❑6.TEMPORARY SITE CLOSURE 4ao I.FACILITY/SITE INFORMATION 4554 S ELDORADO ST.STOCKTON BUSINESS NAME(same4s FACILrfYNAME MOM-Dona Bmues As) 3 FACILITY IIA 1 PR ID# UNIVERSAL FOREST PROD INC FA0003824 PRO232014 NEAREST CROSS STREET FACILITY OWNER TYPE ELDORADO wI E31.CORPORATION [14.LOCAL /DISTRICT' El 5.COUNTY AGENCY- BUSINESS ❑ L GAS STATION ❑ 3.FARM ® 5.COMMERCIAL ❑ 2.INDNIDOAL TYPE ❑ [:] 6.STATE AGENCY- TYPE DISTRIBUTOR E]4.PROCESSOR ❑6.OTHER gD ❑ 3.PARTNERSHIP ❑ 7.FEDERAL AGENCY' 402 TOTAL NUMBER OF TANKS Is facility on Indian Reservation or *If REMAINING AT SITE trust ands? the USowner of UST is a public agency:name tank records.)of division,section or office which operates the UST(This is the contact person for the tank rtcordaJ 404 ❑ Yes ® No 405 UNIVERSAL FOREST PROD INC 406 II.PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407 PHONE(2� � 90Z�DK d08 UNIVERSAL COMPANY (2094 869-6947- `` MAILING OR STREET ADDRESS _ CC 3340 df SS `{ �• fiI QOVGL ctID UT. eos v CITY 4Io STATE41l ZIP CODE (�G 412 McDtl9'r6 IS*(KIWI CA rl_ J J PROPERTY OWNER TYPE ❑ 1.CORPORATION ❑ 2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT 1:16.STATE AGENCY ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY 413 III.TANK OWNER INFORMATION TANKOWNERNAME 614 PHONE !O�`rs/0 6I5 UNIVERSAL COMPANY MAILING OR STREET ADDRESS 3340 TUtIJYJdYSn-B-G_ X55'- 6. E71 apvado ST- CITY 6 417 STATE418 ZIPCODE -{J 2,06419 MODESmn _ S �tm CA TAMC OWNER TYPE ❑ 1.CORPORATION ❑2.INDIVIDUAL 1:14.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY 420 ❑3.PARTNERSHIP 1:15.COUNTY AGENCY ❑ 7.FEDERAL AGENCY IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY(TK)HQ 44- 44-024965 1 Call(916)322-9669 if questions arise 411 V.PETROLEUM UST FINANCIAL RESPONSIBILITY INDICATE METHOD(s) ❑ 1.SELF-INSURED 114.SURETY BOND ❑ 7.STATE FUND ❑ lo.LOCAL GOVT MECHANISM 1-12.GUARANTEE ❑S.LETTER OF CREDIT ❑ 8.STATE FUND&CFO LETTER X❑99.OTHER ❑3.INSURANCE ❑6.EXEMPTION ❑ 9.STATE FUND&CD 422 VI.LEGAL NOTIFICATION AND MAILING ADDRESS Check one box to indicate which address should be used for legal notifications and mailing N1 1.FACILITY ❑2.PROPERTY OWNER ❑3.TANK OWNER 423 Legal notifications and mailins will be sent to the tank owner on) box I or 2 is checked. VII-APPLICANT SIGNATURE Certification-I certify that the information provided herein is one and accurate to the beg ofmy knowledge. SIGNATURE OF APPLICANT DATE 420 PHONE 425 NAME OF APPLICANT(print) 626 TITLE OF APPLICANT 032 STATE UST FACILITY NUMBER(Fm ural u<owy) 428 1998 UPGRADE CERTIFICATE NUMBER(Fo kxsI men*) 429 Is 1998 Compliant?Y UPCF(1/99 revised)