Laserfiche WebLink
UJWD PROGRAM CONSOLIDATED FORT <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (One page per site) Page_of <br /> TYPE OF ACTION ❑1.NEW PERMIT ❑3.RENEWAL PERMIT ❑5.CHANGE OF INFORMATION ❑7.PERMANENTLY CLOSED SITE 400. <br /> (Check one item only) ®4.AMENDED PERMIT (Specify change)Equipment Modification ❑8.TANK REMOVED <br /> [16.TEMPORARY SITE CLOSURE <br /> I, FA�ILi;'�'Y/SI')1')�INFO�EIfiI(f��t ' <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3. FACILITY <br /> ID# ;° z 1. <br /> Fremont Shell <br /> NEAREST CROSS STREET 401. FACILITY OWNER TYPE ❑4.LOCAL AGENCY/DISTRICT* 402. <br /> N.Filbert St. ❑ 1.CORPORATION ❑5.COUNTY AGENCY* <br /> BUSINESS ® 1.GAS STATION ❑3.FARM ❑5.COMMERCIAL 403. ®2.INDIVIDUAL ❑6.STATE AGENCY* <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR [16.OTHER ❑3.PARTNERSHIP [17.FEDERAL AGENCY* <br /> 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. <br /> REMAINING AT SITE or trust lands? office which operates the UST. (This is the contact person for the tank records.) <br /> 1 ❑Yes ®No <br /> PROPERTY OWNER NAME 407 PHONE 408. <br /> Michael Dominguez 209-941-8743 <br /> MAILING OR STREET ADDRESS 409. <br /> 2494 E.Fremont Street <br /> CITYSTATE 411. ZIP CODE 412. <br /> 7CA <br /> Stockton 95205 <br /> PROPERTY OWNER TYPE 0 1.CORPORATION 2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 413. <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> F <br /> � <br /> f <br /> TANK OWNER NAME 414. PHONE 415. <br /> Michael Dominguez 209-941-8743 <br /> MAILING OR STREET ADDRESS a16. <br /> 2494 E. Fremont Street <br /> CITY 417, STATE 418. ZIP CODE 419. <br /> Stockton CA 95205 <br /> TANK OWNER TYPE ❑ 1.CORPORATION ®2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT 6.STATE AGENCY 420. <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> tV,BOARD O -ELTtA '1(�?N LTS3 S`I'O1t +DR ` F Aoc <br /> +t3UTTL3BER` <br /> �. <br /> TY(TK)HQ 44- Call 916 322-9669 if questions arise 421. <br /> INDICATE METHOD(s) ❑1.SELF-INSURED ❑4.SURETY BOND ®7.STATE FUND [110.LOCAL GO V'T MECHANISM 422 <br /> [12.GUARANTEE ❑5.LETTER OF CREDIT ❑8.STATE FUND&CFO LETTER ❑99.OTHER: <br /> ❑3.INSURANCE ❑6.EXk`ErtMPTION�+ y ❑9.STATE FUND&CD <br /> + <br /> T�i a[CA, 1"k' <br /> ` Check one box to indicate which address should be used for legal notifications and mailing. <br /> 1 Legal notifications and mailings will be sent to the tank owner unless box 1 or 2 is checked. ❑ 1.FACILITY [-12. PROPERTY OWNER ®3.TANK OWNER 423. <br /> h <br /> Certification: I certify that 9f information provided herein is true and accurate to the best of my knowledge. <br /> SIGNATU O AP AN DATE 424. PHONE a2s. <br /> 0- 4/18/05 916-373-1152 <br /> NAME OF/APPLICANT(print) 426. TITLE OF APPLICANT 427. <br /> Michael Walton Contractor <br /> 7STATE UST FACILITY NUMBER(Agency use only) 428. 1998 UPGRADE CERTIFICATE NUMBER(Agency use only) 429. <br /> ta Element 1,above. <br /> UPCF Hwfwrc-a(1/99)-1/2 http://www.unidoes.org Rev.02/16/00 <br />