COMPLIANCE INFO_1988-2004 - Laserfiche WebLink

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IFIED PROGRAM CONSOLIDATED FO PR#:PR02314JI FAC#:FA0006388 UNDERGROUND STORAGE TANKS -F (one page per site 1 O TYPE OF ACTION ❑ 1.NEW SITE PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENTLY CLOSED SITE (Check one item only) ❑ 4.AMENDED PERMIT ❑ 8.TANK REMOVED ❑6.TEMPORARY SITE CLOSURE 400 I.FACILITY/SITE INFORMATION 950 W 11TH ST,TRACY BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) g FACILITY ID# PR ID# AMAR GAS&FOOD MART* FA0006388 PR0231401 1 NEAREST CROSS STREET FACILITY OWNER TYPE F-14.LOCAL AGENCY/DISTRICT- ELEVENTH 401 ❑ 1.CORPORATION ❑ 5.COUNTY AGENCY* BUSINESS ® 1.GAS STATION ❑ 3.FARM ❑ 5.COMMERCIAL ❑ 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 operates REMAINING AT SITE trustlands? the UST(This is the contact person for the tank records.) 404 ❑ Yes ® No 405 406 11.PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407 PHONE 408 BASATI CORPORATION 408 390-1055 MAILING OR STREET ADDRESS 409 1384 ALVERNAZ DR CITY 410 STATE 411 ZIP CODE 412 SAN JOSE CA 95121 PROPERTY OWNER TYPE ® 1.CORPORATION ❑ 2.INDIVIDUAL ❑ 4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY ❑3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY 413 III.TANK OWNER INFORMATION TANK OWNER NAME 414 PHONE 415 BASATI CORPORATION 408 390-1055 MAILING OR STREET ADDRESS 416 1384 ALVERNAZ DR CITY 4TTATE 418 ZIP CODE 419 SAN JOSE CA 95121 TANK OWNER TYPE ❑X 1.CORPORATION ❑ 2.INDIVIDUAL ❑ 4.LOCAL AGENCY/DISTRICT ❑ 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- 44-036244 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 1:15.LETTER OF CREDIT ❑ 8.STATE FUND&CFO LETTER X❑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. ® 1.FACILITY ❑2.PROPERTY OWNER ❑3.TANK OWNER 423 Legal notifications and mailing will be sent to the tank owner unless box 1 or 2 is checked. 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 NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 427 STATE UST FACILITY NUMBER(For total o0 only) 428 1 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 Is 1998 Compliant?Y UPCF(1/99 revised)