COMPLIANCE INFO_2002-2009 - Laserfiche WebLink

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• i TINIFIRD PROGRAM C'ONSOLTDATF.D FORM TANKS UNDERGROUND STORAGE TANKS - FACILITY (one page per site) Page_of TYPE OF ACTION ❑ 1.NEW SITE PERMIT ❑3.RENEWAL PERMIT WCHANGE OF INFORMATION ❑ TPERMANENTLY 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 Business As) ) 3 FACILITY ID# COVN b&D NEAREST CROSS STIREET401 FACILITY OWNER TYPE 4.LOCAL AGENCY/DISTRICT* C-6-4V ISI . F• Puskns Ay, ❑ 1.CORPORATION ❑5.COUNTY AGENCY* BUSINESS 1.GAS STATION Lj 3.FARM Lj 5. COMMERCIAL2.INDIVIDUAL C36.STATE AGENCY* TYPE ❑2.DISTRIBUTOR ❑4.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(This is the contact person for the tank records.) UST 404 ❑ Yes )K No 405 N 405 II. PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407 PHONE 408 Phil Z I DE A z03 -1 ti3y -I MAILING OR STREET ADDRESS 409 CITY 410 STATFF 771P CODE 412 PROPERTY OWNER TYPE 1.CORPORATION 2.INDIVIDUAL 4.LOCAL AGENCY/DIS 1 RICT 0 6.STATE AGENCY [13.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY 413 III.TANK OWNER INFORMATION TANK OWNER NAME C 414 PHONE 20ij �� - 1 415 MAI INGQR STREET ADDRESS 416 Sl/c 41 t. L r� CITY 417 STATE 418 ZIP CODE 419 S-1 Oc- I e \-L-C p I CT S TANK OWNER TYPE 1.CORPORATION 2.INDIVIDUAL 4.LOCAL AGENCY/DISTRICT Lj 6.STATE AGENCY 420 [13.PARTNERSHIP [15.COUNTY AGENCY ❑7.FEDERAL AGENCY IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY TK HQ 44- 1 1 1 1 1 Call 916 322-9669 if questions arise 421 V.PETROLEUM UST FINANCIAL RESPONSIBILITY INDICATE METHOD(s) ❑ 1.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 [19.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 I or 2 is checked. ❑ 1.FACILITY PROPERTY OWNER [13.TANK OWNER 423 VII.APPLICANT SIGNATURE Ce ficat on-1 i tha he nnj&prC12cd h ein' e and accurate to the best of my knowledge. S7 �API �j DAT 424 PHON 425 4347 N OE PLI A (print) 426 TIT E OF APPLICANT 427 STATE UST FACILITY NUMBER(For local use only) 428 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 UPCF(1/99 revised) 8 Formerly SWRCB Form A