Laserfiche WebLink
UJVD PROGRAM CONSOLIDATED FOR@ <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (One page per site) Page_of <br /> TYPE OF ACTION ❑1.NEW PERMIT ❑3.RENEWAL PERMIT ®5.CHANGE OF INFORMATION ❑7.PERMANENTLY CLOSED SITE 400. <br /> (Check one item only) ❑4.AMENDED PERMIT (Specify change) ❑8.TANK REMOVED <br /> ❑6.TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Same a.FACILITY NAME or DBA-Doing Business As) 3. FACILITY F A O O 0 ,/ 1 4 1 <br /> ID# . <br /> Fla Ci Shell <br /> NEAREST CROSS STREET 401. FACILITY OWNER TYPE Ll 4.LOCAL AGENCY/DISTRICT- 402 <br /> HWy 12 ❑ 1.CORPORATION [15.COUNTY AGENCY* <br /> BUSINESS 1.GAS STATION 3.FARM 5.COMMERCIAL 403. IN 2.INDIVIDUAL ❑6.STATE AGENCY* <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR [:16.OTHER ❑3.PARTNERSHIP [:17.FEDERAL AGENCY* <br /> TOTAL NUMBER OF TANKS 404. [s facility on Indian Reservation 405. -If owner of UST is a public agency: name of supervisor of division,section or 406. <br /> REMAINING AT SITE or trust lands? office which operates the UST. (This is the contact person for the lank records.) <br /> 3 ❑Yes ®No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPER"IY OWNER NAME 407- PHONE 408. <br /> J.Gilbert Moore (916)443-0890 <br /> MAILING OR STREET ADDRESS 409, <br /> 1831 16"Street <br /> CITY 410. 1 STATE 411, ZIP CODE 412. <br /> Sacramento CA 195814 <br /> PROPERTY OWNER TYPE C31.CORPOPATION 2.INDIVIDUAL Ll 4.LOCAL AGENCY/DISTRICT U 6.STATE AGENCY 413_ <br /> [:13.PARTNERSHIP [15.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> III. TANK OWNER INFORMATION <br /> TANKOWNERNAME 4w. PHONE 415. <br /> J.Gilbert Moore (916)443-0890 <br /> MAILING OR STREET ADDRESS 416. <br /> 1831 16"Street <br /> CITY 417. 1 STATE 418, I ZIP CODE 419, <br /> Sacramento CA 95814 <br /> TANK OWNER TYPE 1.CORPORATION M 2.INDIVIDUAL Lj 4.LOCAL AGENCY/DISTRICT El 6.STATE AGENCY 420. <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY [17.FEDERAL AGENCY <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)H( 44- 0 3 6 0 F6 T_3T__ Call(916)322-9669 if questions arise 421 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ❑ 1.SELF-INSURED ❑4.SURETY BOND ❑7.STATE FUND ❑10.LOCAL GOVT MECHANISM 422 <br /> ❑2.GUARANTEE ❑5.LETTER OF CREDIT ®8.STATE FUND&CFO LETTER ❑99.OTHER: <br /> [13.INSURANCE ❑6.EXEMPTION ❑9.STATE FUND&CD <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. ❑ 1.FACILITY ®2. PROPERTY OWNER ❑3.TANK OWNER 423. <br /> VII. APPLICANT SIGNATURE <br /> Certification: I certify that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNATURE OF APPLICANT DATE 424. PHONE 425_ <br /> 0" (916)443-0890 <br /> N OF APPLICANT(print) 426_ TITLE OF APPLICANT 427 <br /> J.Gilbert Moore Owner <br /> STATE UST FACILITY NUMBER(Agency use only) 428. 1998 UPGRADE CERTIFICATE NUMBER(Agency use only) 429' <br /> (See Data Element 1,above. <br /> UPCF Hwfwre-a(1/99)-1/2 http://www.unidoes.org Rev.02/16/00 <br />