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' •UNIFIED PROGRAM CONSOLIDATE RM <br /> ��' iO� TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY 3� 1\0 <br /> (one page per site) Page_of_ <br /> TYPE OF ACTION ❑ 1.NEW SITE PERMIT ❑3.RENEWAL PERMIT <br /> ®S.CHANGE OF INFORMATION ❑ 7.pERMANENTLY CLOSED SITE <br /> (Check one item only) ❑4.AMENDED PER,%IIT specify change local use only <br /> ❑ 8.TANK REMOVED <br /> ❑6.TEMPORARY SITE CLOSURE 400 <br /> I. FACILITY/SITE INFORMATION <br /> f <br /> FIT'SI,NESSNA\IE(SameasFACILITY NAME orDBA-Doing ,inessAs) 3 FACILITY ID# <br /> l( A GASOLINE#3513 1 <br /> ~ 401FACILITY OWNER TYPE <br /> 4.irUkC�S. ❑4.LOCAL GENCt'iDISTR.ICT* <br /> 401 W. KET MEMAN LANE,LODI, CA 95240 N 1.CORPORATION ❑5.COUNTY AGENCY* <br /> SI.S-F SS ® GAS STATION El 3.FARM 5. COMMERCIAL ❑ 2.INDIVIDUAL ❑6.STATEAGENCY* <br /> CYTE'. ❑2.DISTRIBUTOR ❑4.PROCESSOR❑6. OTHER 403 ❑ 3.PARTNERSHIP ❑7. FEDERAL AGENCY* 402 <br /> 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 <br /> REMAINING AT SITE trustlands? operates the UST(This is the contact person for the tank records.) <br /> ? 404 <br /> -- ❑ Yes ® No 405 loo <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 F818/865-9200 <br /> HONE 408 <br /> GREEN VALLEY GASOLINE LLC <br /> MAILING OR STREET ADDRESS <br /> z010 I A GOURA CT. 109 <br /> CITY 410 STATE 411 ZIP CODE <br /> t11 <br /> i .AGOURA HILLS CA [91301 <br /> j PROPERI•Y OWNER TYPE ❑ 1.CORPORATION 2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY [17.FEDERAL.AGENCY 413 <br /> I <br /> III. TANK OWNER INFORMATION <br /> r TA�WNER NAME 414 PHONE <br /> als <br /> USA PETROLEUM CORPORATION 5-92_ 00 <br /> i-- --- <br /> MIAILINt,OR STREET ADDRESS 818/86 -- <br /> � <br /> 30 101 AGOL'RA CT.. SUITE 200 J <br /> j ley 417 STATE 418 ZIP CODE 1 <br /> s;c <br /> EAGOU A HILLS CA 91301 <br /> r.kNK(-)WNER TYPE 1. CORPORA•CION ❑2.INDIVIDUAL ❑4.LOCAL AGENCY i DISTRICT ❑6 STATE AGENCY 41n <br /> { ❑3.PARTNERSHIP ❑5.COUNTY AGENCY <br /> ❑ FEDgRAL AGENCY <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER J <br /> TY(•I K)HQ 44- 4 2 0 4 6 Call 916)3 22-966 9 if questions arse C2, I <br /> (I V PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> rND1CA1L MI;Ct Or)(s) ® I. SELF-INSURED ❑4 SURE'T'Y BOND ❑7.STATE FUND ❑ 10. L(7C %] GOA"F MECHANISM <br /> ❑2.01JARANTF,E ❑s.LETTER OF CREDIT ❑8.STATE FUND&CFO LETTER ❑ 99.OTHER. <br /> --- ❑3. "NST TANt:•L• [16.EXEMPTION ❑9 STATE FLr1VD&CD <br /> VI. LEGAL NOTIFICATION AND MAILING ADDRESS --- - - -� <br /> I Check nnr hox ro indiratr wh cn add!ess ahouid he used 1,ir Iegai notificaV-ms and msiltng - -� -' - ----•-•-__-_-__ <br /> Le,-A: n-jw.carnnns and martin)s Will be..sent to Cite nk mwnc-,r unless hox I or?is chrrke.d ❑ 1 FACILITY ❑2 PROPERTY O1t'i ? , .^- - <br /> -R �. ';'A.NM:OU1 i Lk 413 <br /> VII.,APPLICANT SIGNATURE <br /> rcrn rsttue and ar curate tr.the res, .,-mv kn„M•ledrte <br /> SIGNATLIRE01:APPLICANT �- --,--'--- - ------ <br /> / IDA"TE a14 PHONE -----_ 4-2 <br /> r5 <br /> ()I/x3/03 818/86.5-9200 <br /> NAME OF AP J. <br /> .INT TITLE OF.-1PPLICANT .117 <br /> JOHN J. SK OPERATIONS MANAGER <br /> STArE UST FACILITY NUMBER(For local use orgy) ;28 1998 LiPGRADE CERTIFICATE NUMBER(For local use only) 29 <br /> I <br /> UPC7 l;')9 revised) f=ormerly S4VRCB Fonn :k <br />