Laserfiche WebLink
FIED PROGRAM CONSOLIDATED FOW <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 S <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 0� <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3. FACILITY <br /> 99 Shell I <br /> ID#L� T] 1 <br /> 00 <br /> NEAREST CROSS STREET 401. FACILITY OWNER TYPE C14.LOCAL AGENCY/DISTRICT* JC:�40R. <br /> Hammer Lane ❑ 1.CORPORATION ❑5.COUNTY AGENCY* 1 <br /> BUSINESS 0 1.GAS STATION [:13.FARM ❑5.COMMERCIAL 403. ®2.INDIVIDUAL ❑6.STATE AGENCY* / <br /> TYPE ❑2.DISTRIBUTOR [:14.PROCESSOR [16.OTHER ❑3.PARTNERSHIP ❑7.FEDERAL AGENCY* J�✓ <br /> TOTAL NUMBER OF TANKS 404. Is facility on Indian Reservation 405. i If owner of UST is a public agency:name of supervisor of division,sectiobq <br /> REMAINING AT SITE or trust lands? office which operates the UST. (This is the contact person for the tank records. I I v <br /> 3 ❑Yes ®No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 408. <br /> Bala'i&Chha a Angle 209-957-5398 <br /> MAILING OR STREET ADDRESS 409. <br /> 7700 Moreland Court <br /> CITY 410. 1 STATE 411. ZIP CODE 412. <br /> Stockton CA 95212 <br /> PROPERTY OWNER TYPE ❑ 1.CORPORATION ®2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 413. <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> III. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> Balaji&Chha a Angle 209-957-5398 <br /> MAILING OR STREET ADDRESS 416• <br /> 7700 Moreland Court <br /> CITY 417. 1 STATE 418, ZIP CODE 419. <br /> Stockton CA 95212 <br /> TANK OWNER TYPE ❑ 1.CORPORATION ®2.INDIVIDUAL ❑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- 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 a„ <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. ❑ I- FA C I I.I"T'Y ❑2. PROPERTY OWNER ®3.TANK OWNER 4 <br /> VII. APPLICANT SIGNATURE <br /> Certification: I certify that a information provided herein ispue and accurate to the best of my knowledge. <br /> SIGNATUAP AN DATE 424. 1 PHONE 425. <br /> 4/18/05 916-373-1152 <br /> NAME OF APPLICANT(print) 426. TITLE OF APPLICANT 427. <br /> Michael Walton Contractor <br /> STATE UST FACILITY NUMBER(Agency use only) 4287 1998 UPGRADE CERTIFICATE NUMBER(Agency use only) 429. <br /> (See Data Element 1,above. <br /> UPCF Hwfwrc-a(1/99)-1/2 http://www.unidoes.org Rev.02/16/00 <br />