COMPLIANCE INFO_2007-2009 - Laserfiche WebLink

Home Browse Search

APR-24-2006 12:57 FROM:TRACY -PIICK & AUTO S 12098325307 Tn 4683433 P.11 O r UNIFIED PROGRAM CONSOLIDATED FORM �'�� TANKS UNDERGROUND STORAGE TANKS - FACILITY v� 4(A (One page per site) Page—of- - age—of— TYPE OF ACTION 1$L NEW PERMIT ❑3 RENEWAL PERMIT I'5,CHANGE OF INFORMATION ❑7.PERMANENTLY CLOSED SITE 400. (Check one item only) ❑4.AMENDED PERMIT (Specify change) ❑9.TANK REMOVED ❑6,TEMPORARY SITE CLOSURE L EACILITYISLTE INFORMATION. BUSINESS NAME(same as FACILITY NnME[orr D,B�A-Doing Business Aa) 3 FACILITY _ 1 T Z� C?�� F NEAREST CROSS STREET 4131 FACILITY OWNER TYPE [D4.LOCAL AGENCY/DISTRICT' 402, 2.._ " Q-0 j -(a_ Gy j 01) Ml.CORPORATION -15.COUNTY AGENCY' BUSINESS JW 1 GAS STATION LJ 3.FARM ❑5 COMMERCIAL 403 ❑2.INDIVIDUAL ❑6,STATE AGENCY' TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR ❑6.OTHER ❑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 405. REMAINING AT SITE or trust lands? office which operates the UST Crhis is the contact person for the tank records.) 3 ❑Yes No 17 Il. PROFERZ Y OWNER INFORMATION PROPERTY OWNER NAME 407 PHONE 409. NP rC DA-4 Iry bEdZ A 2_139 93Z S©b MAILING OR STREET ADDRESS 409 5 9 LIP Na TrJ4 Tf�-44 G l v CITY 410 STATE 411 21P CODE 412 PROPERTY OWNER TYPE U I CORPORATION S2.�QIVIDUAL 4 LOCAL AGENCY/DISTRICT 6.STATE AGENCY 4u. cionic ❑3-PARTNERSHIP ❑5 COUNTY AGENCY ❑7.FEDERAL AGENCY HIL.'TAN K OWNER,INFORMATION TANKOWNERNAME 414 1 PHONE 415 C.E.}p,- 1 r S . -:1 Zo"'k g 3z 415 MAILING OR STREET ADDRESS 3-940 IVa C;f 4 1 �! CITY �t� 417 1 STATE 4113 7.IP CODE 419. \a-A C--P% 61 ;5>' TANK OWNER TYPE ❑1.CORPORATION 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 H 44- Call 916 322-9669 if uestions arise 421 V.PETROLEUM UST FiNANCIAI RESPONSJBILIT—Y, INDICATE METHOD(s) ❑1 SELF-INSURED ❑4.SURETY BOND ❑7 STATE FUND ❑10 LOCAL GOVT MECHANISM 472 ❑2.GUARANTEE ❑5 LETTER OF CREDIT �„B,STATE FUND&CFO LETTER ❑99 OTHER' [13.INSURANCE ❑6-EXEMPTION ❑9 STATE FUND&CD VI.LEGAL iYOTIF>CATION AND MAILING:ADDRESS Check one box to indicate which address should be-used-for legal notifications and,mailing: Legal notifications and mallings will be sent to the tank owner unless box I or 2 is checked. J-9'I FACILITY ❑2 PROPERTY OWNER ❑3.TANK OWNER 423 WT.APPLICANT SIGNATURE ' Certification: 1, t the Information prof ed herein is true and accurate to the best of my knowledge SIGN Fti OF AP ICA DATE 424 PMONE _ 4z5 _0 (oG`1 4 3 2 moa NAM OF APPLICANT(pent) 425 TITLE OF APPLICANT 427 Narq",\ (F 5 t I Lk oix) h*?,Y- STATE UST FACILITY NUMBER(Agency use only) 428 1998 UPGRADE CERTIFICATE NUMBER(Agency ute only) 429 (See Data Element I above. UPCF Hwfwrc-a(1/99)-1/2 http://www.unidocs.org Rev.02/16/00