COMPLIANCE INFO_2006-2011 - Laserfiche WebLink

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LAh- law D PROGR.1,�a%AINSOLIDATED FOR UNDERGROUND STORAGE TANKS - FACILITY p� (one page per site) Page J of TYPE OF ACTION7EW SITE PERMIT ❑3.RENEWAL PERMIT ❑5.CHANGE OF INFORMATION ❑ 7.PERMANENTLY CLOSED SITE (Check one item only ❑4.AMENDED PERMIT specify change local use only _ ❑8.TANK REMOVED ❑&TEMPORARY SITE CLOSURE 400 I. FACILITY/SITE INFORMATION BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Bus As) 3 FAC. ITI ID= 1 5 5 ` Bs� 3 NEAREST CR SS STREETJf, � 401 TA(.MJXY OWNER TYPE 4.LOCAL AGENCY/DISTRICT* / -(I!//vl � .f 1.CORPORATION ❑5.COUNTY AGENCY* BUSINESS ❑1.GAS STATION El 3.FARM U 5. COXImERCI.AL ❑ 2.INDIVIDUAL ❑6.STATE AGENCY* TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR❑6. 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(This is the contact person for the tank records.) 404 ❑ Yes ❑ No 40 406 IL PROPERTY OWNER INFORMATION PROPERTY O ER NAME v1� r. /, /f Q 407 PHONE (115-- �/ J' 408 MAILING OR STREET ADDRESS 409 0YeqaAao VA lky CITY 410 STATE 411 ZIP CODE 412 1.CORPORATION 0 2.INDIVIDUAL U 4.LOCAL AGENCY/DISTRICT U 6.STATE AGENCY ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY 413 M.TANK OWNER INFORMATION TANK OWNER NAME 3,i¢ 414 PHONE 415 54 me- r 416 MAILING OR STREET ADDRESS CITY 417 1 STATE 419 ZIP CODE 419 TANK OWNER TYPE 1.CORPORATION ❑2_INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT Lj 6.STATE AGENCY 420 ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY(TK)HQ 44- 1 1 Call(916)322-%69 if questions arise 421 V.PETROLEUM UST FINANCIAL RESPONSIBILITY ❑L SELF-INSURED ❑4.SURETY BOND [17.STATE FUND ❑10.LOCAL GOVT MECHANISM ❑2.GUARANTEE ❑5.LETTER OF CREDIT ❑8.STATE FUND&CFO LETTER ❑ 99.OTHER: J,3.INSURANCE [16.EXEMPTION ❑9.STATE FUND&CD 422 VLLEGAL 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. ❑ 1.FACILITY Pf2. PROPERTY OWNER ❑3.TANK OWNER 423 VII.APPLICANT SIGNATURE Certi6catioa- 'fy that the information p ed herein is hue and accurate to the best of my knowledge. �iNA F AXCANT CASE 424 TPHONE 425 2i} " 0 15-S 6 7 NAME OF APP ICA I r nl) 426 TITL OF APPL CA 4' STATE UST FACILITY NUMBER(For local use only) 4'-s 1998 UPGRADE CERTIFICATE NUMBER(For local ase only) 429 UPCF(1/99 revised) 8 Formerly SWRCB Form A