COMPLIANCE INFO_2004-2006 - Laserfiche WebLink

Home Browse Search

PROGRAM CONSOLIDATED FruM TANKS qW UNDERGROUND STORAGE TANKS - FACILITY (One page per site) Page 1 of 1(removal) TYPE OF ACTION 0 1.NEW PERMIT 0 3.RENEWAL PERMIT 0 5.CHANGE OF iNFoRmATioN- ❑7.PERMANENTLY CLOSED SITE 400. (Check one item only) 0 4.AMENDED PERMIT(specify change) S.TANK REMOVED 0 6.TEMPORARY SITE CLOSURE .......... ........ ...................... ............ ......................... ....... .............. X., ....... .......... 'X.............. ............. ...... ..................... .. ... ...................................... . .... .. ..... .................................... ................................ .................................. ..... .... .. ..... .......... ....... ...... ................. ..........-....... ...... .. --'. .. ..... ........... .. .. ..... .... .............. ............. ............. . ...... ................................ ............ . . ........ kin .. ....... ............ ......... ........... .. .. . ..... ..... ...... ....... ..... . .... ................ . . ............... ...... .............. .......... BUSINESS NAME(saine aa FAciLiTY NAME or DBA-Doing Business As) g. FACILITY Pacific Bell ID# NEAREST CROSS STREET 4o1. FACILITY OWNER TYPE ❑4.LOCAL AGENCY/DISTRICT* 402. El Portal 19 1.CORPORATION El 5.COUNTY AGENCY* BUSINESS El 1.GAS STATION ❑3.FARM 5.COMMERCIAL 403. [12.INDIVIDUAL ❑6.STATE AGENCY* TYPE [12.DISTRIBUTOR D 4.PROCESSOR El 6.OTHER C1 3.PARTNERSHIP ❑7.FEDERAL AGENCY* TOTAL NUMBER OF TANKS 404. Is facility on Indian Reservation 405. *If owner of UST is a public agency:name of supervisor of division,section or 406. REMAINING AT SITE or trust lands? office which operates the UST. (This is the contact person for the tank records.) One diesel tank 0Yes ONO .......... ....................... ..... ......... ................................... ...... ..................... .. .. ...... ...... .... ........ . ............................... ....... ...................... .......... . .................... ......... ................ ......................... .... ..... .. ............... .. ...... .......... . .... .. ......... ......... ........... ................. ................................ ............. ........... . ..... .... PROPERTY OWNER NAME 407. PHONE 408. Pacific Bell 877-823-9833 MAILING OR STREET ADDRESS 409. 2600 Camino Ramon,Rm.3E000K CITY 410- STATE 411. ZIP CODE 412. San Ramon CA 94583 PROPERTY OWNER TYPE ® 1.CORPORATION 02.INDIVIDUAL [14.LOCAL AGENCY DISTRICT D 6.STATE AGENCY 413. C-1 3.PARTNERSHIP 0 5.COUNTY AGENCY 0 7.FEDERAL AGENCY .......... .. .. ....... .. . ............. .... ............ .%%..... ................ ......... .. ......... ...................... ...... . ........... ................................... ............. ... .. ..................... ........ .. .......... ... . .... ...... ..... ..... .................................... ............... .............................. ...... ...............*;�..--;,� ..... ......... . . ............. ..... ....... ............. .. .............. ... ............................. ....... ....................... ............... %,--.--.%--.-.-.-% %.--I ' - .......... . .................. ............................ ................... V. . ... . ............................ ........... ......................... . ... .......... ..... .. . ....... ............... TANK OWNER NAME 414. PHONE 415. Pacific Bell 877-823-9833 MAILING OR STREET ADDRESS 416. 2600 Camino Ramon,RM.3E000K CITY 417. 1 SCT .- ATE 4181 ZIP CODE 419. San SRamon A94583 TANK OWNER TYPE 1.CORPORATION ❑2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 420. D 3.PARTNERSHIP C3 5.COUNTY AGENCY ❑7.FEDERAL AGENCY .......... --------------------------......................... ............................................................................ ...... ................................ . ..... ................................................................ .................................. ...... ..................... .... ... ... <ff . .. .. .. M . . . ............ -A-C TJ ....... .. . .................................................................. ................ ....................................... ........... ............ ................ ............................. ................ ............. .......... ............... ..................... .. ...... ...................�m...... ........ ............... ... .... .... . .... ...... ....... .. ............... TY(rK)HQ 44- 1 0 1 3 1 1 1 9 1 1 1 4 1 Call(916)322-9669 if questions arise 421. . ............................................. ....... ....... ............... .... . .......... ............................................................ ... ............................... ........................................................ .........%-%........................................ ........... . . ... ... .......... -.... ....... .......... .. ................. .............-...- ..... ................... ...... ... - " .............................. ....... . . .................. ............... ........... ......... . .. ... .. ...... ........ ........... ...... ..... ...... ........... ........... ...... ............... ...........�-v Pj*M-Me"Munyw"M .. ..... ...... . . .............................*. .. .- . ..................... ------- ................. .... ........... .. ................ ....... . ....... .................. INDICATE METHOD(s) 0 1.SELF-INSURED 0 4.SURETY BOND [3 7.STATE FUND 0 10.LOCAL GOVT MECHANISM 422. [12.GUARANTEE 0 5.LETTER OF CREDIT [18.STATE FUND&CFO LETTER 0 99.OTHER: 0 3.INSURANCE 0 6.EXEMPTION F-1 9.STATE FUND&CD ............ ............-..................... --............. ........................................................... .......... --------- ............ . ..... -*. --,-'. ........w�-.. .................. . ..... .........................--...... .............. ................................ .... .......... ........................................... ...... ......... .... ........ .. . .... ..... V Z ... ..... N. 8. ................ .......................... ................. . .........which ........ ............. --------- ............................ ..... ............... Check one box to indicate should be used for legal notifications and mailing. Legal notifications and mailings will be sent to the tank owner unless box I or 2 is checked. ❑ 1.FACILITY 0 2. PROPERTY OWNER ❑3.TANK OWNER 423. ::-* -, , ................ ... . .. X. ......... .......... .......... .............. . ..................................................... ........ ........... ................... ....... . ......................... ......................... . . .................. ...... ..... .... ... ................... . ........... ...... ........ ..... . ..... ...... ............. .............. M.-ATIMAM"S.M.N III ... . .......*................. ................. ................................. ....... ......... .......... ............. ........... .......... ....... ............................................................................... 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. 707-765-1660 NAME OF APPLICANT(print) 426. TITLE OF APPLICANT 427. Scott Tannehill Agent for Pacific Bell STATE UST FACILITY NUMBER(Agency use o*) 428- 1998 UPGRADE CERTIFICATE NUMBER(Agencyuse only) 429. (See Data Element 1,above. UPCF Hwfwre-a(1/99)-1/2 http://www.uxddocs.org Rev.02/16/00