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PROGRAM CONSOLIDATED FO <br />911ED <br />TANKS <br />UNDERGROUND STORAGE TANKS - FACILM <br />(one page per site) ,age <br />TYPE OF ACTION ❑ I. NEW SITE PERMIT [13. RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENTLY CLOSED S <br />(Check one item only) ❑ 4. AMENDED PERMIT specify change local use only ❑ 8. TANK REMOVEQ <br />❑ &TEMPORARY SITE CLOSURE _ <br />I. FACILITY / SITE INFORMATION <br />BUSINESS NAME (sameas FACdrfYNA&Mg DBA-Doig BusinessM) 3 <br />FACB.ITYID# <br />1 <br />USA GASOLINE #65 <br />ADDRESS: 401 <br />FACILITY OWNER TYPE ❑ 4. LOCAL GENCY/DISTRICT" <br />2500 W. LODI, LODI, CA 95242 <br />® 1. CORPORATION ❑ 5. COUNTY AGENCY" <br />❑ 2. INDIVIDUAL ❑ 6. STATE AGENCY* <br />BUSINESS ® 1. GAS STATION ❑ 3. FARM ❑ 5. COMMERCIAL <br />TYPE [12. DISTRIBUTOR ❑ 4. PROCESSOR ❑ 6. OTHER as <br />❑ 3. PARTNERSHIP ❑ 7. FEDERAL AGENCY* Q2 <br />TOTAL NUMBER OF TANKSIs <br />facility on Indian Reservation or <br />*If owner ofUST is a public agency: name of supervisor of division, section or office which <br />REMAINING AT SITE <br />trustlands? <br />operates the UST (I7ris is the contact person for the tank records.) <br />404 <br />❑ Yes ® No as <br />406 <br />IL PROPERTY OWNER INFORMATION <br />PROPERTY OWNER NAME 407 <br />PHONE 408 <br />KRISTMONT WEST, INC. <br />916/772-1600 <br />MAILING OR STREET ADDRESS 409 <br />C/O ERIC GRAGG - BISHOP HAWK; 2830 G STREET <br />CITY 410 <br />STATE d11 <br />ZIP CODE 412 <br />SACRAMENTO <br />CA <br />93816 <br />PROPERTY OWNER TYPE J@LCORPORATION ❑ 2. INDI VIDUAL ❑ 4. LOCAL AGENCY / DISTRICT ❑ 6. STATE AGENCY <br />❑ 3. PARTNERSHIP ❑ 5. COUNTY AGENCY [17. FEDERAL AGENCY 413 <br />III. TANK OWNER INFORMATION <br />TANK OWNER NAME 414 <br />PHONE 415 <br />USA GASOLINE CORPORATION <br />818/865-9200 <br />MAILING OR STREET ADDRESS 416 <br />30101 AGOURA CT., SUITE 200 <br />CITY 417 <br />STATE 418 <br />ZIP CODE 419 <br />AGOURA HILLS <br />CA <br />91301 <br />TANK OWNERTYPE ® 1. CORPORATION ❑ 2. 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 HO 44- 1 3 1 3 17 6 4 Call 916 322-9669 if questions arise 421 <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br />INDICATE METHOD(s) ® 1. SELF-INSURED [14. SURETY BOND [17. STATE FUND ❑ 10. LOCAL GOVT MECHANISM <br />❑ 2. GUARANTEE [15. LETTER OF CREDIT [:18. 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 I or 2 is checked. ❑ L FACEdTY [12. PROPERTY OWNER N 3. TANK OWNER 423 <br />VII. APPLICANT SIGNATURE <br />Certification - I certify that the informatioM <br />herein is true and accurate to the beat of my knowledge. <br />SIGNATURE OF APPLICANT <br />DATE 424 <br />PHONE 425 <br />10/24/01 <br />818/865-9200 <br />NAME OF APPLICANT (print) 426 <br />TITLE OF APPLICANT 427 <br />JOHN J. ZISK <br />OPERATIONS MANAGER <br />STATE UST FACILITY NUMBER (F. local usa.*) 428 <br />1998 UPGRADE CERTIFICATE NUMBER (For local use only) <br />429 <br />UPCF (1/99 revised) Formerly SWRC13 Form A <br />