COMPLIANCE INFO_2002-2008 - Laserfiche WebLink

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ONIFIED PROGRAM CONSOLIDATED WI A�2N TANKS UNDERGROUND STORAGE TANKS - FACILITY (one page per site) Page _ of _ TYPE OF ACTION ❑ t. NEW SITE PERMIT ❑ 3. RENEWAL PERMIT E 5.CHANGE OF INFORMATION (Check one item only) ❑ 4. AMENDED PERMIT specify he local use onI ❑ 7.PERMANENTLY CLOSED SITE p Y cang Y ❑ 8. TANK REMOVED n 6 TF A- POR e R v S! FE or - ro c - _.__-._ ___--__- _. .... ...-.,.,,,."., 400 I. FACILITY / SITE INFORMATION BUSINESS NAIME (Saint as FACILITY NADIE or DBA - Doing Business As) 3 FACILITY ID# USA GASOLINE #3502 1 I .ADDRESS: 401 1 FACILITY OWNER TYPE ❑ 4. LOCAL GENCY/DISTRICT* 1 1q. CHEROKEE LANE, LODI, CA 95240 ® 1. CORPORAI'ION El5. COUNTY AGENCY* 0 2. INDIVIDUAL ❑ 6. STATE AGENCY* . SINESS DQ 1. GAS STATION D 3. FARM 5. COMMERCIAL I TYPE ❑ 2. DISTRIBUTOR ❑ 4. PROCESSOR ❑ 6. OTHER 403 ❑ 3. PARTNERSHIP ❑ 7. FEDERAL AGENCY* jTOTAL NUMBER OF TANKS Is facility on Indian Reservation or aoz *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.) �3 404 ❑ Yes ® No =15 aoB C II. PROPERTY OWNER INFORMATION PROPERTY OWNER NAME PHONE USA PETROLEUM CORPORATION ms 818/865-9200 MAILING OR STREET ADDRESS 30101 AGOURA CT. w ! CITY 410STATE 011 ZIP CODE ate i AGOLTRA HILLS C k 91301 PRUI ERTY OWNER TYPE ® I. COR POR AT10N 2. INDIVIDUAL 4. LOCAL AGENCY - DISTRICT ❑ 6. STATE AGENCY [:13. PARTNERSHIP 115. COUNTY AGENCY ❑ 7. FEDERAL, AGENCY 413 L- III. TANK OWNER INFORMATION TANK UWNERNAME ala PHONE 415 US��A_PETROLEUM CORPORATION 818/865-9200 I MAILING OR STREET ADDRESS -- 301601 AGOURA CT., SUITE 200 at6 cI7 Y 417 STATE 418 ZIP CODE J19 ! AGOTJRA HILI.S CA 191301 r TANK i XVNER TYPE ® 1. CORPORATION ❑ 2. INDIVIDUAL ❑ 4. LOCAL AGENCY ; D1S'rRiCT ❑ 6. STATE 'AGENCY azo _ ❑ 3. PARTNERSHIP ❑ 5. CUI!NTY AGENCY ❑ 7. FFDERAJ. AGENCY IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER (TK) HQ 44-4 12 10 14 ' 6 1 Call (916) 322-9669 if questions arise 421 i V. PETROLEUM UST FINANCIAL RESPONSIBILITY !ND)c.v METHOD(s) ® 1. SELF-INSURED ❑ 4. SURETY BOND--- t] " ..T,\'fF FUND u to. I.CK:Ai tsi?�"r MECH:'WISM ❑ 2. GUARANTEE ❑ 5. LETTER OF CREDIT ❑ 8. s,rA'rF FUND & CFO LETTER ❑ ?9. r)TIiF:R: ❑ 3. INSURANCE ❑ 6. EXEMPTION [1 9. STATE FUND & CD 422- i--------- •- -- ---- j VI. LEGAL NOTIFICATION AND MAILING ADDRESS n cis c•oc bo a 1., mdr.:ate which address should be used for legal notificalions and mailing. - -" l.ega) notifications and mailings will be .rent v, he tank owner unitsabox I or 2 is checked. 0 1 FACII,I'I'Y ❑ 2. PROPER"rl' Ut1J)vl?A � ; ; n; ;) C?,�^�R 42 VIL-APPLICANT SIGNATURE feWj'-' m I c.•�rrty that the �ntormauon (+r "Aed hereur is true and accUtate Lathe benot'wo knowledge --- SIGNATURE OF APPLICANT -- DATE ata P}IUNE vis _._._. 01/03/03 818/81515-9200 NAMFOFAPi'Ll(-%N'I'( ttnt - P ) TITLE OF .APPLICANT 4z7 JOHN J. ZISK OPERATIONS MANAGER \TE UST FACILITY NUMBER (For local use only) 128 1998 UPGRADE CERTIFICATE NUMBER (For local use ont-y) I i I ¢9 UPCF ( 1/c)q revised) Formerw SWRC13 Form A