|
D PROGRAM CONSOLIDATED FORM
<br /> TANKS
<br /> UNDERGROUND STORAGE TANKS - FAciuTv
<br /> (one page Per site) Page-of
<br /> TYPE OF ACTION D 1.NEW SITE PERMIT N 3.RENEWAL PERMIT ❑5.CNANGE Of INFORMATION
<br /> ❑ 7.PEFIMANENTLY CLOSED SITE
<br /> (Brock ono nem Only) ❑4.AMENDED PERMIT R"Or"charpB local use only O e.TANK REMOVED
<br /> 'l; /'r:r.* ./ ,;:, ,,,.tr i•I'./..• ❑&TEMPORARY SITE CLOSURE 400
<br /> (�i/. �l/ r J. � %i{,r `i .I � %��/�r%%i^.%'iir r...%/:•%i': 51,.-: ::i' n'r'?%A;�: ir/, .e .
<br /> .!•$/' i�;G ;! I ' /�;;F:J _/./ L �'/h f SjYf �Ji;..: / r r lN,r r F..:ii %
<br /> ,,,% r/i.,/, /•+.�� /.�,� '.Ir/?^;i'�:'� �`�j t?.��C f�r� •�Q .,� ;;i;,//."j� .;�/%`i'3.;,'�yrf/ %✓/•! ;yr,,,yf;<.
<br /> :.I . /// .v•n•.G� /hr'//.v /i:d rn b'.; I r. 'Grrv..r %' ;,.r../,�� /+%. Jr ,r .�:r'r�i/J/r/.�Grj
<br /> BUSINE33 NAME 19en4 s4 rAoam RAM2 or oaA_oowa eu.nms A.I d � ' .�ptp'�r',
<br /> NEAREST CROSS STREET wt FACILI E 4,LOCAL GENCY/DISTRICT-
<br /> ® 1.CORPORATION ❑5.COUNTY AGENCY'
<br /> BUSIN S 1, AS STATION 3. ARM 5. COMMERCIAL ❑ 2.INDIVIDUAL ❑6,STATE AGENCY'
<br /> TYPE ❑2.DISTRIBUTOR ❑d.PROCESSOR❑8. OTHER wa ❑ 3.PARTNERSHIP ❑7.FEDERAL AGENCY• 4W
<br /> TOTAL NUMBER OF TANKS IS faCulty on Ifldl]fl RBservadDn Or 'll ouster 01 U3i is 5 public A90.CY name o19aPON11501 oldivirion,SCCIIOn W o/llce
<br /> REMAINING AT SITE trusllands? whlth Operates the UST(Thl.Is the can(ew person for Me lank Word&)
<br /> 2 .o. ❑ Yes ® No 405 406
<br /> .j,/,/.'ijy:G'i'r..l:i'(G:%�;:. ./.Ay •r.. „�.� .,.%rii/% `,%r/•%. :i'i,!'i�%�%i:(, G'r'.•.J.. ,r%,�., r; r r.r, .Y.,
<br /> / r. �•: . / r r,'r ;rJi {`r ri/.IL,(y�QFEf'��TCR�1'fi �y r%/ /i r// r!G% Ji✓/ , r '//r
<br /> PROPERTY OWNER NAME r / r r'J5 : r /, ,'r!/,� •/ . r , , ✓/�%',
<br /> rwT PHONE 4tb
<br /> Connie Beck,Trustee of the Ro L. Beck Estate 818-789.8063
<br /> MAILING OR STREET ADDRESS
<br /> 3900 Lon rid a Ave. .�
<br /> CITY di0 STATE 411 ZIP CODE 41z
<br /> Sherman Oaks CA 91423
<br /> PROPERTY OWNER TYPE 1.CORPORATION 2.INDIVIDUAL Lj 4,LOCAL AGENCY/DISTRICT M 6 .STATE AGENCY
<br /> ❑3.PARTNERSHIP LI5.COUNTY AGENCY ❑7.FEDERAL
<br /> / n]
<br /> i':/5,,,�tfil,'%�:'. '�'1�nUrr::Y°:•;%' :�•v :/,i��'JJ'f''T:;{.rya�' q:k.'S:: iY:' r/ / /•.. "';.t.. .,, 4:e: .Y(,Yra o1,'^.y/ti',�n .I.ry
<br /> (i '(I itf %'%i ,/r r. /. �tri/ '/%% 1'�? n�7Er3lN1.A/rlt� l /iry i:i/r./r/r/1//��' /. r/F�,%f✓J r / ryr .',
<br /> //r• /.• // / "/�:..y/ir/r/ .MJ//i q',,.r !'iii.i f 'u.Y/:ir.. F//.� ,: :lr,. //� /S r/f.��
<br /> TANK OWNER NAME 414 PHONE 415
<br /> Ultramar Inc. 558592-0247
<br /> MAILING
<br /> OR STREET ADDRESS .te
<br /> 685 W Third Street
<br /> CITY a7 STATE 41a ZIP CODE ITB
<br /> Hanford CA 93230-5000
<br /> TANK OWNER TYPE ® 1.CORPORATION 2.INDIVIOUAL U 4.LOCAL AGENCY I DISTRICT El 6,STATE AGENCY .z0
<br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY
<br /> '�.i• %i�,�::i�'i'"%f�•{./IS' , r is%``/J'. :%.;; r:�.. ':/?:f.:! i n:k"yh4r.,
<br /> ! r /i!r .1XjQO�1R�?UF ��y�TIO�S11E A. r
<br /> +.J, f, .+. • ;rvY,MQE %%,>? �/'�.✓il�//r.,�^.. ",•
<br /> 7Y TK HQ 44- 2 4 8 6 0 77
<br /> Call 916 322.96691f uestions arse 421
<br /> �C 'i; "iy'%.;' rif. . .//,r•% . . 777-. , r r,,.;.'/,C,r,(rS��,Ni/^;.r./'//(( p
<br /> io/ ! r Y�i'r 5�VV4ar �� .li���,Tf//,✓/ lr %�r� J"rI�/.i/
<br /> . +.'.".., • Fr w,:,r '//, r1. !F/,4 %�i.. ./fir 9,%'i:/•ii:: ��%�. 'r�if;'//•;�r.T"r�.��r/rjl•.4 if/�%%
<br /> INDICATE 0 1.SELF-INSURED [14.SURETY BOND ❑7.STATE FUND ❑10.LOCAL GOVT MECHANISM
<br /> METHOD(s) 0 2.GUARANTEE ❑5.LETTER OF CREDIT ❑8.STATE FUND 6 CFO LETTER ❑ 99,OTHER,_
<br /> ❑3.INSURANCE ❑6.EXEMPTION ❑9.STATE FUND 8 CD
<br /> % 1 11
<br /> ,���:, r i/i,:r:..a,.�'iii�':'f�: {{(';: .r,. " :{.. 'r.:i1i:'i'Ski: �r.> ,�. {•/' i; ,/ r„ 4u r
<br /> z+{f/jr ;i%',: 'i!/ri.%i'?%/',.%%%< f'' Er. 'y':r', ,, .rr r! U/. 'c.'/F ie/%z:i.;r',.;•",�,< , .jry y.. flFlC/�,
<br /> ,.. {¢;ir 'r ,r.,.' r/ rrr: r , :•Y', .j:• "� , '/ ,;..l,l."d H/, /%/li'r ' eir✓/i l'�ir/i�!i
<br /> Chock one boa to Indino cate which eddlpse Mould ba used tar legal norawalions we meding
<br /> Legal no motions and mairings will bo sant to Nro lank owner unless boa 1 or 2 e Ch4Ckdd. ❑ 1.FACILITY [12 PROPERTY OW NEA 103.TANK 42a
<br /> `i%/;'{;: ��: %:/i✓{f';'r.t '�a:`.;fY^.' i:anv��,%rp,:✓ . ,Cr:}r.JU'. r��,. :'K�.r(�.yN�'- :}/,/ ,n. ,� ..r. :c ,•, •r
<br /> /J L/s .,. /, �'/. >, �.:r.,'//, r i .rr'/.S' ✓//:-0Y'rA rr! V.. /�rr� 4r�fr�'v/
<br /> CeN4itOlion-I esraly that the intormelgn provided herein h;riw and aCGarale to IIIc bell 41 my knowledge.
<br /> SIGNATURE OF APPLICANT DATE 424 PHONE 425
<br /> 4/8/03 559-583-3398
<br /> NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 427
<br /> Dennis Smith Operations& Environmental Specialist
<br /> STATE UST FACILITY NUMBER IFw anal oo enyl no 1988 UPGRADE CERTIFICATE NUMBER IFor klnl u.a oryyl 420
<br /> UPCF(1/99 revised) Formerly SW RCB Form A
<br />
|