COMPLIANCE INFO_1994-2006 - Laserfiche WebLink

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IFIED PROGRAM CONSOLIDATED FO ' '� PR#:PRO231867 FAC#:FA0003W UNDERGROUND STORAGE TANKS -7F !IL av X03 (one page per site) TYPE OF ACTION ❑ I.NEW SITE PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENTLY CLOSED SIT /�/a (Check one item only) ❑4.AMENDED PERMIT I ❑ 8.TANK REMOVED V 1 ❑6.TEMPORARY SITE CLOSURE 400 1.FACILITY/SITE INFORMATION 345 N SAN JOAQUIN ST,STOCKTON BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 FACILITY ID# PR ID# PACIFIC BELL FA0003959 PR0231867 1 NEAREST CROSS STREET FACILITY OWNER TYPE SAN JOA UIN 401 ❑ 1.CORPORATION ❑4.LOCAL /DISTRICT• ❑ 5.COUNTYY 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.) aoa El Yes ® No 405 GLORIA LOPEZ ao6 II.PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407 PHONE 408 PACIFIC BELL ENVIRONMENTAL MGT 209 943-4128 MAILING OR STREET ADDRESS 409 PO BOX 15038/3524 MARCONI RM B CITY 410 1 STATE 411 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 als PACIFIC BELL ENVIRONMENTAL MGT 209 943-4128 MAILING OR STREET ADDRESS 416 PO BOX 15038/3524 MARCONI RM B CITY 417 STATE 418 ZIP CODE 419 SACRAMENTO CA 95851 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- 44-001027 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 ❑6.EXEMPTION ❑ 9.STATE FUND&CD 422 V1.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 1 PHONE 425 NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 427 STATE UST FACILITY NUMBER(For local=only) 4281998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 Is 1998 Compliant?Y UPCF(1/99 revised)