COMPLIANCE INFO_1998-2004 - Laserfiche WebLink

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ED PROGRAM CONSOLIDATED FO TANKS UNDERGROUND STORAGE TANKS - FACILITY (one page per site) Page_of 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 specify change local use only ❑ 8.TANK REMOVED ❑6.TEMPORARY SITE CLOSURE 400 I. FACILITY /SITE INFORMATION BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 FACILITY IDI 1 Union 76#2611194 NEAREST CROSS STREET 401 FACILITY OWNER TYPE ❑4.LOCAL GENCY/DISTRICT* Grantline Rd ® 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 REMAINING AT SITE trustlands? operates the UST(This is the contact person for the tank records.) 3 404 ❑ Yes ® No 405 406 II. PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407 PHONE 408 Conoco Phillips Company MAILING OR STREET ADDRESS 409 PO Box 52085 CITY 410 1 STATE 411 ZIP CODE 412 Phoenix AZ 85072-6038 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 Conoco Phillips Company 510-245-5176 MAILING OR STREET ADDRESS 416 76 Broadway CITY 417 STATE 418 ZIP CODE 419 Sacramento I CA 1 95818 TANK OWNER TYPE ® 1.CORPORATION ❑2.INDIVIDUAL 4.LOCAL AGENCY/DISTRICT Lj 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- 1 4 1 1 19 19 18 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 ❑ 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. Legal notifications and mailings will be sent to the tank owner unless box I or 2 is checked. ❑ 1.FACILITY ❑2. PROPERTY OWNER ®3.TANK OWNER 423 VII. APPLICANT SIGNATURE Certification-I certify that the information Rrovided herein is true and accurate to the best of my knowledge. SIGNATURE OF APPLICANT DATE 424 PHONE 425 5/30/03 (916)635-2444 NAME OF APPLICANT(prin 426 TITLE OF APPLICANT 427 Becky Weaver Agent for Owner STATE UST FACILITY NUMBER(For local use only) 428 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 UPCF(1/99 revised) 171 Formerly SWRCB Form A