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ED PROGRAM CONSOLIDATED FORM
<br /> TANKS
<br /> UNDERGROUND STORAGE TANKS - FACIuTY
<br /> (one page per site) Page_01
<br /> TYPE OF ACTION 13 1.NEW SITE PERMIT 0 9.RENEWAL PERMIT ❑S.CHANGE OF INFORMATION ❑ ?.PERMANENTLY CLOSED SITE
<br /> Ieherk we 4ero"1 O 4.AMENDED PERMIT a Illi q,wps 190411""oroy C3 S.TANK REMOVED
<br /> M 6.TEMPORARY SITE CLOSURE 400
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<br /> BUSINESS NAME Is4m4 44 yaCUTr NAue w Du_Dane eusdm4asl
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<br /> 2 ''F7/,v,i✓lr 1
<br /> Beacon Station M3492 � �%/?l !r:/ ;
<br /> NEAREST CROSS STREET 4ot FA ILI E 4.LOCAL GENCYA)IST CT'
<br /> ® 1.CORPORATION ❑5.COUNTY AGENCY'
<br /> BUSINES 1.GAS STATION 3. ARM 5. COMMERCIAL ❑ 2.INDIVIDUAL ❑6.STATE AGENCY'
<br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR❑6. OTHER aD ❑ 3.PARTNERSHIP ❑7.FEDERAL AGENCY' 4W
<br /> TOTAL NUMBER OF TANKS 16 faCelly on Indian Rosanna on Dr 'II Ownerol VST is a oublk agency.name vt eupernwr of diysl4n,section or office
<br /> REMAINING AT BITE trustfanda? which operates Ike UST(TMs is the cont..t Perron for His lank reeords,)
<br /> 2 404 ❑ Yes N No `KO
<br /> 406
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<br /> PROPERTY OWNER NAME 407 PHONE 4a
<br /> Connie Beck,Trustee of the Roy L. Beck Estate 818-789.8083
<br /> MAILING OR STREET ADDRESS 409
<br /> 3900 Longridge Ave.
<br /> CITY 410 STATE 411 ZIPCODE 412
<br /> Sherman Oaks CA 91423
<br /> PROPERTY OWNER TYPE LJI.CCRPORATION 2.INDIVIDUAL Ej 4,LOCAL AUV.NUTI DI61 RIU1 Ll 6.STATE AGENCY
<br /> ❑3.PARTNERSHIP ❑S.COUNTY AGENCY ❑7,FEDERAL 413
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<br /> TANK OWNER NAME 414 PHDNE 4ts
<br /> Ultramar Inc. 559582.0241
<br /> MAILING OR STREET ADDRESS 419
<br /> 685 W Third Street
<br /> CITY o7 STATE 4n ZIP CODE 410
<br /> Hanford CA1 93230-5000
<br /> TANK OWNER TYPE ®1.CORPORATION 2.INDIVIDUAL U 4.LOCAL AGENCY/DISTRICT 0 6.STATE AGENCY 42D
<br /> 0 3,PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY
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<br /> 0 1 Cell 916 322-9669 if questions arse 421
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<br /> INDICATE N 1.SELF-INSURED [14.SURETY BOND ❑7.STATE FUND ❑10.LOCAL GOVT MECHANISM
<br /> METHOD(s) ❑2.GUARANTEE ❑S.LETTER OF CREDIT ❑8.STATE FUND 8 CFO LETTER ❑ 99,OTHER:_
<br /> ❑3.INSURANCE ❑6.EXEMPTION ❑9.STATE FUND 8 CD 422
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<br /> Check abox to irldla9le which a4dresa should be used br lapel " arena eM 1t1mTPlg.
<br /> Legal ooeficabon,and mailings will be sent d Ure Lank owner whies box 1 Or 2 6Chocked, ❑ 1.FACILITY [12. PROPERTY OWNER ®3.TANK ^423
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<br /> CCn nCOlJOn-I cantly Thal Na inlonnetion pro~herein is ow and aoc%trale to Ike best rd my kriowledge.
<br /> SIGNATURE OF APPLICANT DATE 424 PHONE 4Es
<br /> 4/8/03 559-563-3398
<br /> NAME OF APPLICANT(pant) 490 TITLE OF APPLICANT 427
<br /> Dennis Smith Operations& Environmental Specialist
<br /> STAT9 UST FACILITY NUMBER IFw deal w myi as 1990 UPGRADE CERTIFICATE NUMBER(Forkmel the onM 4za
<br /> UPCF(1199 revised) Formerly SWRCS Form A
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