COMPLIANCE INFO_2002-2005 - Laserfiche WebLink

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IED PROGRAM CONSOLIDATED RM . 1, Q r L TANKS q p� UNDERGROUND STORAGE TANKS - FACILITY (one page per site) 1065 Page _ of _ TYPE OF ACTION ❑1. NEW SITE PERMIT ❑3. RENEWAL PERMIT ®S. CHANGE OF INFORMATION (Specify change - 07. PERMANENTLY CLOSED SITE (Check one item only) 04. AMENDED PERMIT local use only) ❑8. TANK REMOVED 400 ❑6. TEMPORARY SITE CLOSURE TY (TK) HQ 4 4 - 0 2 0 7 3 3 Call (916) 322-9669 if questions arise 421 INDICATE METHOD(S) ❑ 1. SELF-INSURED ❑ 4. SURETY BOND 7. STATE FUND ❑ 10. LOCAL GOV=T MECHANISM ❑ 2. GUARANTEE ❑ 5. LETTER OF CREDIT ❑ 8. STATE FUND & CFO LETTER ❑ 99. OTHER: 422 ® 3. INSURANCE E]6. EXEMPTION E]9. STATE FUND & CD ------------ Check one box to indicate which address should be used for legal notifications and mailing- ❑ 1. FACILITY 2. PROPERTY OW NER 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 URE F APP AN BUSINESS NAME (Same as FACILITY NAME or DBA- Doing Business As) 3 FACILITY ID #a (510) 245-5218 NAMr= OF APPLICANT(PM) TITLE OF APPLICANT 426 Pam Ruesga Regional Compliance Specialist 1 Kayo Oil Co. #2705446 BUSINESS SITE ADDRESS 401 FACILITY OWNER TYPE ❑ 4. LOCAL AGENCY/DISTRICT- 1403 COUNTRY CLUB BLVD ® 1. CORPORATION 2. INDIVIDUAL ❑ 3. PARTNERSHIP ❑ 5. COUNTY AGENCY - ❑ 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 REMAINING AT SITE Is facility on Indian Reservation or -If owner of UST is a public agency: name of supervisor of trustlands? division, section or office which operates the UST. (This is the contact person for the tank records.) 4 404 ❑ Yes ® No 405 406 11. PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407 1(714) PHONE 408 428-6572 Kayo Oil Co. MAILING OR STREET ADDRESS 409 P.O. Box 52085 CITY 410 STATE 411 AZ ZIP CODE 412 85072 Phoenix PROPERTY OWNER TYPE ❑ 2. INDIVIDUAL ❑ 4. LOCAL AGENCY/ DISTRICT ❑ 6. STATE AGENCY 413 ❑ 1. CORPORATION ® 3. PARTNERSHIP ❑ 5. COUNTY AGENCY ❑ 7. FEDERAL AGENCY 111. TANK OWNER INFORMATION TANK OWNER NAME 414 PHONE 415 Kayo Oil Co. MAILING OR STREET ADDRESS 416 P.O. Box 52085 CITY 417 STATE 418 AZ ZIP CODE 419 85072 Phoenix 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) HQ 4 4 - 0 2 0 7 3 3 Call (916) 322-9669 if questions arise 421 INDICATE METHOD(S) ❑ 1. SELF-INSURED ❑ 4. SURETY BOND 7. STATE FUND ❑ 10. LOCAL GOV=T MECHANISM ❑ 2. GUARANTEE ❑ 5. LETTER OF CREDIT ❑ 8. STATE FUND & CFO LETTER ❑ 99. OTHER: 422 ® 3. INSURANCE E]6. EXEMPTION E]9. STATE FUND & CD ------------ Check one box to indicate which address should be used for legal notifications and mailing- ❑ 1. FACILITY 2. PROPERTY OW NER 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 1998 UPGRADE CERTIFICATE NUMBER (For local use only) 428 UPCF (1/99 revised) 5 Formerly SWRCB Form P. Certifica' I certify that the information provided herein is true and accurate to the best of my knowledge. SIG URE F APP AN DATE 424 PHONE 425 (510) 245-5218 NAMr= OF APPLICANT(PM) TITLE OF APPLICANT 426 Pam Ruesga Regional Compliance Specialist STATE UST FACILITY NUMBER (For local use only) 427 1998 UPGRADE CERTIFICATE NUMBER (For local use only) 428 UPCF (1/99 revised) 5 Formerly SWRCB Form P.