COMPLIANCE INFO_2002-2012 - Laserfiche WebLink

Home Browse Search

IFIED PROGRAM CONSOLIDATED FORNO PR#:PR0231309 FAC#:FA0003756 UNDERGROUND STORAGE TANKS -FACILITY �� 3 751! (one page per site) TYPE OF ACTION ❑ 1.NEW SITE PERMIT Ed3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENTLY CLOSED SIT (Check one item only) ❑ 4.AMENDED PERMIT ❑ 8.TANK REMO U ❑6.TEMPORARY SITE CLOSURE A Oy 400 1.FACILITY/SITE INFORMATION 1725 ACKERMAN DR.LODI BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 FACILITY ID# PR ID# KISHIDA GEORGE INC FA0003756 PR0231309 NEAREST CROSS STREET FACILITY OWNER TYPE ACKERMAN 401 ❑ 1.CORPORATION E]4.LOCAL AGENCY/DISTRICT* ❑ 5.COUNTY AGENCY' BUSINESS ❑ L GAS STATION ❑ 3.FARM ® 5.COMMERCIAL ❑ 2.INDIVIDUAL ❑ 6.STATE AGENCY* TYPE [:] 3.PARTNERSHIP 402 ❑2.DISTRIBUTOR ❑4.PROCESSOR [:] 6.OTHIER 403 ❑ 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 operates REMAINING AT SITE trustlands? the UST(This is the contact person for the tank records.) aoa El Yes ® No 405 GEORGE KISHIDA 406 II.PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407 PHONE 408 KISHIDA GEORGE INC 209 368-0603 MAILING OR STREET ADDRESS 409 1725 ACKERMAN DR CITY 410 I STATE 411 ZIP CODE 412 LODI CA 95240 PROPERTY OWNER TYPE ❑ 1.CORPORATION ❑ 2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY ❑3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY 413 III.TANK OWNER INFORMATION TANK OWNER NAME ala PHONE a1s KISHIDA GEORGE INC 209 368-0603 MAILING OR STREET ADDRESS 416 1725 ACKERMAN DR CITY 417 STATE 418 ZIP CODE 419 LODI CA 195240 TANK OWNER TYPE ❑ 1.CORPORATION ❑ 2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY 420 ❑ 3.PARTNERSHIP ❑O 5.COUNTY AGENCY 1:17.FEDERAL AGENCY IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY(TK)HQ 44- 1 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 1:12.GUARANTEE ❑5.LETTER OF CREDIT ❑ 8.STATE FUND&CFO LETTER X❑99.OTHER ❑3.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 ❑3.TANK OWNER 423 Legal notifications and mailing will be sent to the tank owner unless box 1 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 PLIC T r DATE 424 PHONE 425 2-2 6 -0 2 Zog-36 -or�o3 n i NAME O APPLICANT(print) 426 TITLE OF APPLICANT 427 i Cz �l&tj STATE UST FACILITY NUMBER(For local ue only) 428 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 Is 1998 Compliant?Y UPCF(1/99 revised)