BILLING_1985-2004 - Laserfiche WebLink

Home Browse Search

IVIED PROGRAM CONSOLIDATED FO PR .1`112 3 1 7 0 7 F.AC :FA000394S UNDERGROUND STORAGE TANKS -FACILIT*�j)It 111 I D3 I (one page per site) TYPE OF ACTION ❑ I.NEW SITE PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ,�❑/7.PERMANENTLY CLOSED SITE (Check one item only) ❑ 4.AMENDED PERMIT IAB.TANK REMOVED ❑6.TEMPORARY SITE CLOSURE �t 409 I.FACILITY/SITE INFORMATION 24081 S MOUNTAIN HOUSE PKWY,TRACY BUSINESS NAME(S.ae as FACILITY NAME a DBAFACILITYID4 PRD" P G&E TRACY MAINTENANCE STATION FA0003948 PRO231707 ST CROSS STREET 401 FACILITY OWNER TYPE ❑ 4,LOCAL AGENCY/DISTRICT' PA ERSON PASS ❑ I CORPORATION ❑ 5.COUNTY AGENCY' BUSINESS E] 1.GAS STATION ❑3.FARM F-15.COMMERCIAL 2.INDIVIDUAL ❑ b.STATE AGENCY" TYPE ❑ 2.DISTRIBUTOR ❑4.PROCESSOR ❑ b.OTHER 403 ❑ 3.PARTNERSHIPE] 402 ].FEDERAL AGENCY' TOTAL RUMER OF TANKS Is facility on Indian Reservation or gfowner of UST is a public agency:name of supervisor ofdivision,section or office which operates REMAINING AT SITE tru Glands? the UST(This is the contact person for the tank records.) ❑ Yes ®No 405 MIKE PAINTER 406 \ II.PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407 PHONE 408 209 835-1983 MAILING OR STREET ADDRESS 409 PO BOX 250 CITY 410 STATE 411 ZIP CODE 412 ANTIOCH CA 94509 PROPERTY OWNER TYPE ® 1.CORPORATION ❑ 2.INDIVIDUAL ❑ 4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY ❑3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY 413 III.TANK OWNER INFORMATION TANKOWNERNAME 414 PHONE 415 P G&E CONN PIPELINE OPERATOR 510 943-3811 MAILING OR STREET ADDRESS 416 375 N WIGET LANE STE 250 CITY 417 STATE 418 ZIPCODE 419 WALNUT CREEK CA 94598-2412 TANK OWNER TYPE ❑X 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- 44-024839 1 Call(916)322-9669 if questions arise d21 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 CREDIT ❑ 8.STATE FUND&CFO LETTER El 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. ® 1.FACILITY ❑2.PROPERTY OWNER ❑3.TANK OWNER 423 Legal notifications and mailing will be sem to the tank owner unless box 1 or 2 is ebecked. VII.APPLICANT SIGNATURE Certification-1 certify that the intercedes Provided herein is true and accurate to the best of my knowledge. SIGNATURE OF APPLICANT DATE 424 1 PHONE 425 NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 427 STATE UST FACILITY NUMBERFm kcal lady) 428 1998 UPGRADE CERTIFICATE NUMBER(Forlool a..only) 429 Is 1998 Compliant?Y UPCF(1/99 revised)