COMPLIANCE INFO_2002-2008 - Laserfiche WebLink

Home Browse Search

We UNIFIED PROGRAM(UP) FORM UNDERGROUND STORAGE TANKS - FACILITY (one page per site) Page q TYPE OF ACTION ❑1.NEW SITE PERMIT ❑3.RENEWAL PERMIT ®5.CHANGE OF INFORMATION ❑ TPERMANENTLY CL(Check one item only) ❑2.INTERIM PERMIT ❑4.AMENDED PERMIT ❑6.TEMPORARY SITE CLOSURE ❑ 8.TANK REMOVEDI. FACILITY/SITE INFORMATION BUSINESS NAME(Same as FACILITY NAME or DBA) 3 FACILITY ID# Unified 1` s `n� NEAREST CROSS STREET Q`C FACILITY OWNER TYPE 4.LOCAL AGENCY/DISTJ* Wa"fie✓loo 1.CORPORATION ❑5.COUNTY AGENCY* `n( BUSINESS ❑1.GAS STATION 3. FARM ❑5. COMMERCIAL ❑ 2.INDIVIDUAL ❑6.STATE AGENCY TYPE ®2. DISTRIBUTOR ❑4.PROCESSOR❑6. OTHER 403 ❑ 3.PARTNERSHIP ❑7. FEDERAL AGENCY* 402 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 REMAINING AT SITE trustlands? office which operates the UST(This is the contact person for the tank records.) 404 ❑ Yes ® No 405 406 II. PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407 1 PHONE 408 ifif nC. (12,3) 2L,-Af-S't0 MAILING OR STREET ADDRESS , 409 5200 H In Ste--eek' A4e_vn '. envi rav"eA0.1 CITY 410 STATE41 ZIP CODE 412 Cornmev-c'2 CA O©qo PROPERTY OWNER TYPE 1.CORPORATION ❑2. INDIVIDUAL ❑4. LOCAL AGENCY/DISTRICT Ej 6.STATE AGENCY ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7. FEDERAL AGENCY 413 III.TANK OWNER INFORMATION TANK OWNER NAME 414 PHON E, 415 (,Lnifieok Cir rs ,rh(. (IZ3) ZU44; . O MAILING OR STREET ADDRESS 416 5zhv SH�� a 5 kee+ A Irv)I = Chv iyovi vAev►fe-1 u eG l+ln -Sr, , CITY 417 STATE ala ZIP CODE 419 C oVV)yy)eve-2 C A q 6040 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- 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 GOV'T MECHANISM ❑2.GUARANTEE OF 5. LETTER OF CREDIT ❑8.STATE FUND&CFO LETTER ❑ 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. 423 Legal notifications and mailings will be sent to the tank owner unless box 1 or 2 is checked. ❑ 1.FACILITY ❑2. PROPERTY OWNER [a 3.TANK OWNER VII.APPLICANT SIGNATURE Certification-I cert' that the information provided herein is true and accurate to the best of my knowledge. SI URE O APP NT DATE 424 1 PHONE 425 Z- Zfv'O L .323 2(04-52.C)c� NAYE OF AP ICAN rint) 426 TITLE OF APPLICANT 42T S ta\/e-i . 55-ex1#Ae.c� IE <l Fe k OFFICIAL USE ONLY DATE RECEIVED CUPA PA DISTRICT/INSPECTOR STATE UST FACILITY NUMBER 42e 1998 UPGRADE CERTIFICATE NUMBER 429 UP FORM(1/2000 Version) 1 UPF_LAC4:06_USTA THE CUPAs OF LOS ANGELES COUNTY