COMPLIANCE INFO_2002-2005 - Laserfiche WebLink

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FIED PROGRAM CONSOLIDATED RM 1/74 C -5I TANKS 41 UNDERGROUND STORAGE TANKS -FACILITY (one page per site) 1065 Page _ of TYPE OF ACTION _ (Check one dem only) ❑1. NEW SITE PERMIT ❑3. RENEWAL PERMIT ®5. CHANGE OF INFORMATION (Specify change - ❑7. PERMANENTLY CLOSED SITE ❑4. AMENDED PERMIT local use only) ❑8. TANK REMOVED 400 ❑6. TEMPORARY SITE CLOSURE TY (TK) HO 4 4 0 2 0 1 7 3 3 Call (916) 322-9669 if questions arise 421 ttD(HOS) ❑ 1. SELF-INSURED ❑ 4. SURETY BOND 7. STATEISIR11 1131 FUND ❑ 10. LOCAL GOV=T MECHANISM ❑ 2. GUARANTEE ❑ 5. LETTER OF CREDIT 1718. STATE FUND & CFO LETTER El 99. OTHER: ® 3. INSURANCE ❑ 6. EXEMPTION ❑ 9. STATE FUND & CD 422 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 mailings will be sent to the tank owner unless box 1 or 2 is checked. I. FACILITY/ SITE INFORMATION SIG ttl URE F APP AN BUSINESS NAME (Same as FACILITY NAME or DBA - Doing Business As) 3 FACILITY ID # TITLE OF APPLICANT 426 Regional Compliance Specialist Kayo Oil Co. #2705446 EA BUSINESS SITE ADDRESS 401 FACILITY OWNER TYPE ❑ 4. LOCAL AGENCY/DISTRICT* 1403 COUNTRY CLUB BLVD ® 1. CORPORATION ❑ 5. COUNTY AGENCY- [:] 2. INDIVIDUAL ❑ 3. PARTNERSHIP ❑ 6. STATE AGENCY' ❑ 7. FEDERAL AGENCY- 402 BUSINESS TYPE ® 1. GAS STATION ❑ 3. FARM ❑ 5. COMMERCIAL ❑2. DISTRIBUTOR ❑ 4. PROCESSOR ❑ 6. OTHER 403 TOTAL NUMBER OF TANKS Is facility on Indian Reservation or *If owner of UST is a public agency: name of supervisor of REMAINING AT SITE trustlands? division, section or office which operates the UST. 4 ❑ Yes (This is the contact person for the tank records.) ® No 406 404 405 II, PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407 PHONE 408 Kayo Oil Co. 1(714) 428-6572 MAILING OR STREET ADDRESS 409 P.O. Box 52085 CITY 410 STATE 411 ZIP CODE 412 Phoenix AZ 85072 PROPERTY OWNER TYPE ❑ 2. INDIVIDUAL ❑ 4. LOCAL AGENCY/ DISTRICT ❑ 6. STATE AGENCY 413 ❑ 1. CORPORATION ❑ 3. PARTNERSHIP ❑ 5. COUNTY AGENCY ❑ 7. FEDERAL AGENCY III. TANK OWNER INFORMATION TANK OWNER NAME 414 PHONE 415 Kayo Oil Co. MAILING OR STREET ADDRESS 416 P.O. Box 52085 CITY 417 Phoenix STATE 418 AZ 185072 ZIP CODE 419 TANK OWNER TYPE ❑ 2. INDIVIDUAL ❑ 4. LOCAL AGENCY/ DISTRICT ❑ 6. STATE AGENCY 420 ® 1. CORPORATION ❑ 3. PARTNERSHIP ❑ 5. COUNTY AGENCY ❑ 7. FEDERAL AGENCY TY (TK) HO 4 4 0 2 0 1 7 3 3 Call (916) 322-9669 if questions arise 421 ttD(HOS) ❑ 1. SELF-INSURED ❑ 4. SURETY BOND 7. STATEISIR11 1131 FUND ❑ 10. LOCAL GOV=T MECHANISM ❑ 2. GUARANTEE ❑ 5. LETTER OF CREDIT 1718. STATE FUND & CFO LETTER El 99. OTHER: ® 3. INSURANCE ❑ 6. EXEMPTION ❑ 9. STATE FUND & CD 422 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 mailings will be sent to the tank owner unless box 1 or 2 is checked. STATE UST FACILITY NUMBER (For local use only) 427 1 1998 UPGRADE CERTIFICATE NUMBER (For local use only) 428 UPCF (1/99 revised) 5 Formerly SWRCB Form A Certifica^ I certify that the information provided herein is true and accurate to the best of my knowledge. SIG ttl URE F APP AN DATE 424 1 PHONE 425 (510) 245-5218 NAM OF APPLICANT ( t) Pam Ruesga TITLE OF APPLICANT 426 Regional Compliance Specialist STATE UST FACILITY NUMBER (For local use only) 427 1 1998 UPGRADE CERTIFICATE NUMBER (For local use only) 428 UPCF (1/99 revised) 5 Formerly SWRCB Form A