Laserfiche WebLink
U .ED PROGRAM CONOOLIDATED FOR <br /> TANKS A� <br /> UNDERGROUND STORAGk TANKS - FACILITY v 1 <br /> (One paLc per site) Page_of �t <br /> TYPE OF ACTION ❑ 1.NEW PERMIT [13.RENEWAL PERMIT [15.CHt NGE OF INFORMATION ❑7.PERMANENTLY CLOSED SITE 400. <br /> (Check one item only) ®4.AMENDED PERMIT (Specify change)Equipment Modification ❑8.TANK REMOVED <br /> ❑6.TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION <br /> BUSINESS NAMF(Same as FAULITY NAME or DBA-Doing Business As) 3. 1 FACILITY <br /> Waterloo Shell 413 ID# S 1. <br /> NEAREST CROSS STREET 401. FACILITY OWNER TYPE ❑4.LOCAL AGENCY/DISTRICT* 402. <br /> Wilcox Rd. ❑ 1.CORPORATION ❑5.COUNTY AGENCY* <br /> BUSINESS E 1.GAS STATION ❑3.FARM 5.COMMERCIAL 403. E 2.INDIVIDUAL, ❑6.STATE AGENCY* Op <br /> ❑TYPE 2.DISTRIBUTOR El4.PROCESSOR ❑6.OTHER ❑3.PARTNERSH1P ❑7.FEDERAL AGENCY* <br /> TOTAL NUMBER OF TANKS 404. Is facility on Indian Reservation 405. *If owner of UST is a p blic 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 tank records.) <br /> 2 ❑Yes E No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 408. <br /> Bill&Cathie Norby 209-931-3674 <br /> MAILING OR STREET ADDRESS 409. <br /> 4315 Waterloo Rd. <br /> CITY 410. STATE 411. ZIP CODE 412, <br /> Stockton I CA 95205 <br /> PROPERTY OWNER TYPE ❑ 1.CORPORATION E 2.INDIVIDUAL El 4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 413. <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> 111. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415 <br /> Bill&Cathie Norby 209-931-3674 <br /> MAILING OR STREET ADDRESS 416. <br /> 4315 Waterloo Rd. <br /> CITY 417. 1 STATE 418. ZIP CODE 419. <br /> Stockton CA 95205 <br /> TANK OWNER TYPE 1.CORPORATION E 2.INDIVIDUAL El 4.LOCAL AGENCY/DISTRICT 6.STATE AGENCY 420. <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 1 1 1 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 /> ❑3.INSURANCE ❑6.EXEMPTION ❑9.STATE FUND&CD <br /> VI. LEGAL NOTIFICATIONAND 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 E 3.TANK OWNER 423. <br /> VII. APPLICANT SIGNATURE <br /> Certification: I certify that it information provided herein is true and accurate to the best of my knowledge. <br /> SIGNATUREO P DATE 424. PHONE 425. <br /> -� 4/04/05 916-373-1152 <br /> NAME OF&PLICANT(print) V 4426TITLE OF APPLICANT 427. <br /> Michael Walton Contractor <br /> STATE UST FACILITY NUMBER(Agency use only) 1998 UPGRADE CERTIFICATE NUMBER(Agency use only) 429. <br /> (See Data Element 1,above. <br /> UPCF Hwfwrc-a(1/99)-1/2 http://www.unidocs.org Rev.02/16/00 <br />