Laserfiche WebLink
• ` IFIED PROGRAM CONSOLIDATEDIV TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page per site) Page__L of 5 <br /> TYPE OF ACTION 11 1.NEW SITE PERMIT [13.RENEWAL PERMIT [25.CHANGE OF INFORMATION ElTPERMANENTLY 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 I SITE INFORMATION <br /> BUSINESS NAME(Seine as FACILITY NAME or DBA-Doing Business As) 3 FACILITY ID# 1 <br /> Tosco#256981 -Pacific 76 <br /> NEAREST CROSS STREET Bot FACILITY OWNER TYPE ❑4.LOCAL GENCY/DISTRICT' <br /> 4707 Pacific Avenue March Lane, STOCKTON Z 1.CORPORATION ❑5.COUNTY AGENCY' <br /> BUSINESS ® 1.GAS STATION ❑3.FARM ❑5. COMMERCIAL ❑ 2.INDIVIDUAL ❑6.STATE AGENCY' <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR❑6. OTHER 403 ❑ 3. PARTNERSHIP ❑7.FEDERAL AGENCY' Boz <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 <br /> REMAINING AT SITE trustlands? which operates the UST(This is the contact person for the to <br /> records.) <br /> 2 404 ❑ Yes Z No 405 _ _. _ 405 <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408 <br /> TOSCO CORPORATION <br /> 409 <br /> MAILING OR STREET ADDRESS <br /> P.O. Box 52084 <br /> CITY 410 STATE 411 ZIP CODE 412 <br /> Phoenix AZ 85072-2084 <br /> PROPERTY OWNER TYPE Z 1.CORPORATION ❑2. INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑U.STATE AGENCY <br /> ❑3.PARTNERSHIP [15.COUNTY AGENCY [17.FEDERAL 413 <br /> III. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> TOSCO CORPORATION 925-277-2319 <br /> MAILING OR STREET ADDRESS 416 <br /> P.O. Box 52084 <br /> CITY 4n STATE 418 ZIP CODE a1s <br /> Phoenix AZ 85072-2084 <br /> TANK OWNER TYPE Z 1.CORPORATION [12.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 420 <br /> ❑3.PARTNERSHIP [15.COUNTY AGENCY ❑7. FEDERAL AGENCY <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY TK HO 44- 0 3 6 2 4 4 Call 916 322-9669 if questions arise 421 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE ® 1.SELF-INSURED ❑4.SURETY BOND ❑7.STATE FUND ❑10.LOCAL GOVT MECHANISM <br /> METHOD(s) 712.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. az3 <br /> Legal notifications and mailings will be sent to the tank owner unless box 1 or 2 is checked. ❑ 1.FACILITY ❑2. PROPERTY OWNER Z 3.TANK OWNER <br /> VII.APPLICANT SIGNATURE <br /> Certification-I certify that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGN TURE OF PLI�AN T DATE 424 PHONE 425 <br /> 3117100 (925) 313-9700 <br /> NA E OF A&LIUANT(print) 425 TITLE OF APPLICANT 427 <br /> Zaiga Gianino (of RHL Design Group, Inc.) Agent for Tosco <br /> STATE UST FACILITY NUMBER(For local use only) 428 1998 UPGRADE CERTIFICATE NUMBER(For lorzl use only) 429 <br /> UPCF (1199 revised) 0 <br /> • Formerly SWRCB Form A <br />