COMPLIANCE INFO_1985-2005 - Laserfiche WebLink

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PROGRAM CONSOLIDATED FO � TANKS UNDERGROUND STORAGE TANKS - FACILI (one page per site) Page-of- TYPE OF ACTION ❑ 1.NEW SITE PERMIT ;;3.RENEWAL PERMIT ❑5.CHANGE OF INFORMATION ❑ TPERMANFNTLY CLOSED SITE (Check one item only) ❑4.AMENDED PERMIT specify change local use only ❑ 8.TANK REMOVED ❑6.TEMPORARY SITE CLOSURE 400 I. FACILITY/SITE INFORMATION BUSINESS NAME(so=as FACILITY NAME or DBA-Doing Business As) 3 FACILITY 1D# S v A e R 5 TO f NEAREST CROSS STREET 401 FACILITY OWNER TYPE ❑4.LOCAL GENCY/DISTRICT* Be S S-1 C A V e ❑ 1.CORPORATION ❑5.COUNTY AGENCY* BUSINESS 1.GAS STATION ❑3.FARM ❑5. COMMERCIAL 2.INDIVIDUAL ❑6.STATE AGENCY* TYPE ❑2.DISTRIBUTOR [14.PROCESSOR[16. OTHER 403 ❑ 3.PARTNERSHIP ❑7.FEDERAL AGENCY* 402 TOTAL NUMBER OF TANKS Is facility on Indian Reservation or *If owner of UST is a public agency:name of supervisor of division,section or office which REMAINING AT SITE trustlands? operates the UST('Ibis is the contact person for the tank records.) --H A E IE 3 404 ❑ Yes K No 405 aob II. PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407.] PHONE aos MY.--t mv-5 - M es tr �� zo 9) 835- �¢- 38 MAILING OR STREET ADDRESS 409 1.5- W• 1 / - S T, CITY 410 1 STATE 411 ZIP CODE o - 3 7� 412 PROPERTY OWNER TYPE"' ❑ L CORPORATION 2.INDIV IDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY 413 III.TANK OWNER INFORMATION TANK OWNER NAME M4 I PHONE- ---------- 4:5 Mr + MrS R o- m ,5 1 r /OL, 203 MAILING OR STREET ADDRESS 416 r ` CITY G 417 STATIC 418 =DL n 419 �Y` TANK OWNER TYPE Lj 1.CORPORATION Ptl INDIVIDUAL Lj 4.LOCAL AGENCY/DISTRICTF1 6.STATE AGENCY ago [13.PARTNERSHIP ❑5.COUNTY AGENCY [:17.FEDERAL AGENCY IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY(TK)HQ 44= Call(916) 322-9669 if questions arise V1 V.PETROLEUM UST FINANCIAL RESPONSIBILITY INDICATE METHOD(S) El1.SELF-INSURED ❑4.SURETY BOND ❑7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM ❑2.GUARANTEE ❑5.LETTER OF CREDIT ❑8.STATE FUND&CFO LETTER ❑ 99.OTHER: ❑3-INSURANCE ❑6.EXEMPTION ❑9.STATE FUND&CD 422 VI.LEGAL NOTIFICATION AND MAILING ADDRESS Check one box to indicate which address should be used for legal notifications and mailing. Legal notifications and mailings will be sent to the tank owner unless box 1 or 2 is checked. X 1.FACILITY ❑2. PROPERTY OWNER ❑3.TANK OWNER 473 VII.APPLICANT SIGNATURE Certification-I certify that the information provided herein is true and accurate to the best of my knowledge. SIGNATURE OF APPLICANT DATE 424 PHONE 425 X09 -'161- C33 NAME OF APPLICANT(P t) 426 TITLEOF APPLICANT 427 C. Cc -e- IT J 0t../e.S M0,90 ,STATE UST FACILITY NUMBER(For local use only) 428 _ 1998 UPGRADE CERTIRCA NUMBER(For iocai use only) 429 UPCF(1/99 revised) 171 Formerly SWRCB Form A