Laserfiche WebLink
UIVED PROGRAM CONSOLIDATED FOR <br /> TANKS Vl"u <br /> UNDERGROUND STOAAGk TANKS - FACILITY <br /> tt (One page per site) Page_of <br /> _f <br /> TYPE OF ACTION [11.NEW PERMIT [13.RENEWAL PERMIT ❑5.CHt NGF 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 /> 1. FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3. 1 FACILITY <br /> Waterloo Shell 41 315 <br /> 1D# g I I I I I JT� <br /> 1. <br /> NEAREST CROSS STREET 401. PACILITY OWNER TYPE El 4.LOCAL AGENCY/DISTRICT* 402, <br /> Wilcox Rd. ❑ 1.CORPORATION ❑5.COUNTY AGENCY* <br /> BUSINESS ® 1.GAS STATION ❑3.FARM 5.COMMERCIAL 403• ®2.INDIVIDUAL [16.STATE AGENCY* <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR [16.OTHER ❑3.PARTNERSHIP ❑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 ®No <br /> I1. 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. 1 STATE 411. ZIP CODE 412 <br /> Stockton CA 95205 <br /> PROPERTY OWNER TYPE [11.CORPORATION 2 2.INDIVIDUAL Ej 4.LOCAL AGENCY/DISTRICT El 6.STATE AGENCY 413 <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> 111. TANK OWN FORMATION <br /> TANK OWNER NAME p414. PHONE 415. <br /> Bill&Cathie Norby , '* 209-931-3674 <br /> MAILING OR STREET ADDRESS "a 416. <br /> 4315 Waterloo Rd. j•6, <br /> CITY 417. 1 STATE 418. ZIP CODE 419. <br /> Stockton CA 95205 <br /> TANK OWNER TYPE 1.CORPORATION Z 2.INDIVIDUAL Ll 4.LOCAL AGENCY/DISTRICT 0 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- I I I I 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 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 1 or 2 is checked. ❑ 1.FACILITY ❑2. PROPERTY OWNER ®3.TANK OWNER 423. <br /> VII. APPLICANT SIGNATURE <br /> Certification: I certify that information provided herein is true and accurate to the best of my knowledge. <br /> SIGNAT O P DATE 424 1 PHONE 42' <br /> ��WA -- 4/04/05 916-373-1152 <br /> NAME OF APPLICANT(print) 426. TITLE OF APPLICANT 427 <br /> Michael Walton Contractor <br /> STATE UST FACILITY NUMBER(Agency use only) 428.7 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 />