COMPLIANCE INFO_1985-2006 - Laserfiche WebLink

Home Browse Search

F~ 11-114-01;1- UD 1-12-OZUD PROGRAM CONSOLIDATED FORM 16 �Nll 3 Ib Z FAC#:FA0003849 UNDERGROUND STORAGE TANKS -FACILITYV / (one page per site) TYPE OF ACTION ❑ 1.NEW SITE PERMIT ❑ 3.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 2551 E LOUISE AVE.MANTECA BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 FACILITY ID# PR ID# WORLD COM FA0003849 PR0231659 l NEAREST CROSS STREET FACILITY OWNER TYPE El 4.LOCAL AGENCY/DISTRICT* LOUISE 401 PK1.CORPORATION ❑ 5.COUNTY AGENCY* BUSINESS ❑ 1 GAS STATION ❑ 3.FARM © 5.COMMERCIAL ❑ 2.INDIVIDUAL ❑ 6.STATE AGENCY* TYPE ❑ 2 DISTRIBUTOR ❑ 4.PROCESSOR ❑ 6.OTHER 403 ❑ 3.PARTNERSHIP ❑ 402 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.) 404 ❑ Yes ® No 405GAAkT ��w/.t `�y r^ S 1 406 II.PROPERTY OWNER INFORMATION PROPERTY OWNER NAME �r� 407 PHONE l 5 r�1 aos MAILING OR STREET ADDRESS G 409 `ALI u Q N)e G lei,%v'" CITY 410 STATE 411 ZIP CODE 412 *A- -rx PROPERTY OWNER TYPE ® 1.CORPORATION ❑ 2.INDWIDUAL ❑ 4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY ❑3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY 413 III.TANK OWNER INFORMATION TANK OWNER NAME 414 PHONE 415 MAILING OR STREET ADDRESS 416 -2 QAR L) �:� STATE CITY 417 --�r als ZIP CODE 419 .ft*yW*ft5 f%\Gl\ GSr�Sy" -4 Ik% s --1530%1y . TANK OWNER TYPE 1.CORPORATION ❑ 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- 44-024813 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 ❑2.GUARANTEE ❑5.LETTER OF CREDIT ❑ 8.STATE FUND&CFO LETTER ❑X 99.OTHER �3.INSURANCE 1:16.EXEMPTION ID 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. -0- 1.FACILITY ❑2.PROPERTY OWNER .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 ofmy knowledge. SIGNATURE OF APPLICANT f)A DATE 424 PHONE 425 NAME OF APPLICANT(print) _ 426 TITLE OF APPLICANT 427 I ace e,�,{*) Uzi,4N -�4-7 .r,7. •%t o,4,\ '1t1.1r.1� 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)