COMPLIANCE INFO_2001-2005 - Laserfiche WebLink

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cTk ' FIED PROGRAM CONSOLIDATED FOR d3 PR#:PR02318 6 FAC#:FA00 57 j UNDERGROUND STORAGE TANKS«F L �u o3 (one page per site TYPE OF ACTION ❑ I.NEW SITE PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENTLY CLOSED SITE I� (Check one item only) ❑ bnigis'wn"`''s' ❑ 8.TANK REMOVED �l�T.\�J_ 4.AMENDED PERMIT sp&rrydwgc�alusQ � _ ❑6.TEMPORARY SITE CLOSURE o I.FACILITY/SITE INFORMATION 124 W ELM ST,LODI L;>� BUSINESS NAME(Same m FACILITY NAIME or DBA•Doing Business As) 3 FACILITY ID# PR ID# PACIFIC BELL FA0003957 PR0231866 1 NEAREST CROSS STREET FACILITY OWNER TYPE p 4.LOCAL AGENCY/DISTRICT- ELM 401 ❑ 1.CORPORATION ❑ 5.COUNTY AGENCY" BUSINESS ® 1.GAS STATION ❑3.FARM ❑ 5.COMMERCIAL ❑2.INDIVIDUAL ❑ 6.STATE AGENCY- TYPE ❑IB3PARTNERSHIP 402 ❑ 2.DISTRUTOR ❑4.PROCESSOR ❑ .6.OTHER 403 ❑ 7.FEDERAL AGENCY' TOTAL NUMBER OF TANKS Is facility on Indian Reservation or *Ifowner 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 29 No 405 PACIFIC BELL 406 II.PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407 PHONE 408 PACIFIC BELL ENVIRONMENTAL MGT 415 823-7777 MAILING OR STREET ADDRESS 409 PO BOX 15038/3524 MARCONI RMB CITY 410 1 STATE 411 1 ZIP CODE 412 SACRAMENTO CA 95851 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 PACIFIC BELL ENVIRONMENTAL MGT 415 823-7777 MAILING OR STREET ADDRESS 416 PO BOX 15038/3524 MARCONI RM B CITY 417 1 STATE 418 ZIP CODE 419 SACRAMENTO CA 195851 TANK OWNER TYPE Q I.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- 44-001529 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 ❑X 99.OTHER ❑3.INSURANCE 1:16.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 I 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 local ut only) 428 1998 UPGRADE CERTIFICATE NUMBER(Forlocal useonly) 429 Is 1998 Compliant?Y UPCF(1/99 revised)