COMPLIANCE INFO_1996-2003 - Laserfiche WebLink

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UIIPIED PROGRAM CONSOLIDATED FOM _2�'1 L TANKS UNDERGROUND STORAGE TANKS - FACILITY (one page per site) Page _ f TYPE OF ACTION ❑l.NEW SITE PERMIT [:13.RENEWAL PERMIT ®5.CHANGE OF INFORMATION(Specify change- [:17.PERMANENTLY CLOSED SITE (Check one item only) ❑4.AMENDED PERMIT local use only) ❑8.TANK REMOVED 400 ❑6.TEMPORARY SITE CLOSURE t.FACILITY/SITE INFORMATION BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 FACILITY ID# 1 Tosco Corporation #255886/5886/31010 NEAREST CROSS STREET 401 FACILITY OWNER TYPEn 1-5/MARCH LN ® 1. CORPORATION ❑ 4 5. COUNTY A. LONTYAGENCY' DISTRICT' ❑2. INDIVIDUAL ❑ BUSINESS TYPE ®1.GAS STATION ❑ 3.FARM ❑5.COMMERCIAL ❑ 3. PARTNERSHIP ❑ 6. STATE AGENCY' 02.DISTRIBUTOR ❑ 4.PROCESSOR ❑ 6.OTHER ❑ 7. FEDERAL AGENCY' 402 403 TOTAL NUMBER OF TANKS Is facility on Indian Reservation or If owner of UST is a public agency:name of supervisor of REMAINING AT SITE trustlands? division,section or office which operates the UST. (This is the contact person for the tank records.) 3 404 ❑Yes ®No405 406 Ii.PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407 PHONE 408 Tosco Corporation (925)277-2404 MAILING OR STREET ADDRESS 409 P.O. Box 52085 CITY 410 STATE 411 ZIP CODE 412 Phoenix AZ 85072 PROPERTY OWNER TYPE ❑ 2. INDIVIDUAL ❑ 4. LOCAL AGENCY/DISTRICT ❑ 6. STATE AGENCY 413 ❑ 1. CORPORATION ❑ 3. PARTNERSHIP ❑ 5. COUNTY AGENCY ❑ 7. FEDERAL AGENCY fit.TANK OWNER INFORMATION TANK OWNER NAME 414 PHONE 415 Tosco Corporation (925)277-2404 MAILING OR STREET ADDRESS 416 P.O. Box 52085 CITY 417 STATE 418 ZIP CODE 419 Phoenix AZ 85072 TANK OWNER TYPE ❑ 2. INDIVIDUAL ❑ 4. LOCAL AGENCY/DISTRICT ❑ 6. STATE AGENCY 420 ® 1. CORPORATION ❑ 3. PARTNERSHIP ❑ 5. COUNTY AGENCY ❑ 7. FEDERAL AGENCY IV BOARD OF EQI IA1 17ATION I-IST STORAGE FEE ACCOUNT NUMBER TY(TK)HQ 4 1 4 1 0 3 6 1 2 4 4 Call(916)322-9669 if questions arise 421 RET-ROI E-1111MUST FINANCIItRE�RONSIISIIII 13X INDICATE MET ❑ 1. SELF-INSURED ❑ 4. SURETY BOND 7. STATE FUND ❑ 10. LOCAL GOV=T MECHANISM ® 2. GUARANTEE ❑ 5. LETTER OF CREDIT ❑ 8. STATE FUND&CFO LETTER ❑99. OTHER: ❑ 3. INSURANCE ❑ 6. EXEMPTION ❑ 9. STATE FUND&CD 422 Check one box to indicate which address should be used for legal notifications and mailing. ❑ 1. FACILITY ❑ 2. PROPERTY OWNER ® 3. TANK OWNER 423 Legal notifications and mailings will be sent to the tank owner unless box 1 or 2 is checked. Certificati I certify that the information provided herein is true and accurate to the best of my knowledge. SIG URE APPLI ANT, DATE / 424 PHONE 425 �DO�- (925) 277-2404 NAME OF AP LICANT(pnnt) TITLE OF APP ANT 426 Janette M. Thompson For Tosco Corporation Regional Compliance Specialist STATE UST FACILITY NUMBER(For local use only) 427 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 428 UPCF(1/99 revised) 5 Formerly SWRCB Form A