COMPLIANCE INFO_2009-2012 - Laserfiche WebLink

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t IF IED PROGRAM CONSOLIDATED F TANKS UNDERGROUND STORAGE TANKS - FACILITY (one page per site) TYPE OF ACTION ❑ 1.NEW SITE PERMIT [:13.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENTLY CLOSED SITE (Check one item only) ❑4.AMENDED PERMIT ❑ 8.TANK REMOVED ❑6.TEMPORARY SITE CLOSURE 400 I.FACILITY/SITE INFORMATION BUSINESS NAME(Same as FACILITY NnME or DBA-Doing Business As) 3 FACILITY ID# DICK N SAVE* FA0001946 1 T � FT NEAREST CROSS STREET FACILITY OWNER TYPE ❑4.LOCAL AGENCY/DISTRICT* aoI ❑ 1.CORPORATION ❑ 5.COUNTY AGENCY* BUSINESS ❑ 1.GAS STATION ❑ 3.FARM ❑ 5.COMMERCIAL ® 2.INDIVIDUAL" ❑6.STATE AGENCY* TYPE ❑ 2.DISTRIBUTOR [:14.PROCESSOR ❑6.OTHER 403 ❑ 3.PARTNERSIIIPao2 ❑ 7.FEDERAL AGENCY* 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.) 6 404 ❑Yes ®No 405 406 II.PROPERTY OWNER INFORMATION PROPERTY OWNER NAME ao7HONE 408 MOHAMAD S MATAR 209 948-3009 MAILING OR STREET ADDRESS 409 1314 DEB CT CITY 410 STATE 411 ZIP CODE 412 SAN JOSE CA 95120 PROPERTY OWNER TYPE ❑ 1.CORPORATION ® 2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY 03.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY ata III.TANK OWNER INFORMATION TANK OWNER NAME 414 PHONE 415 MOHAMAD S MATAR 209 948-3009 MAILING OR STREET ADDRESS 416 1314 DEB CT CITY 417[STATE 418 ZIP CODE 419 SAN JOSE CA 95206 TANK OWNER TYPE ❑ 1.CORPORATION x❑2.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)HQ 44- T44-024533 I 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 1:199.OTHER 1913.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. ® 1.FACILITY ❑2.PROPERTY OWNER 1:13.TANK OWNER 423 Legal notifications and mailing will be sent to the tank owner unless box I or 2 is checked. VII.APPLICANT SIGNATURE Certification-I certify that the information provided herein is true and accurate to the best of my knowledge. SIGNATURE OF APPLICANT DATE 424 I PHONE 425 (209)948-3009 NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 427 MOHAMAD S MATAR OWNER STATE UST FACILITY NUMBER(For local ue only) 428 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 N UPCF(1/99 revised)