Laserfiche WebLink
IFIF.D PROGRAM CONSOLIDATED p <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (One page.per site) Page 1 <br /> of 9 <br /> TYPE OF ACTION ❑ L NEW PERMIT ❑3.RENEWAL.PERMIT ®5.CHANGE OF INFORMATION ❑7.PERMANENTLY CLOSED SITE 400. <br /> (Check one item only) [14.AMENDED PERMIT (Specify change)New overfill and dispenser containment ❑8.TANK REMOVED <br /> ❑6.TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION <br /> BUSINESS NAME(same as FACILITY NAME:or DILA-Wing Business As) 3. 1 FACILITY <br /> Grant Line Shell 2375 Grant Line Rd. Trac CA ID# ,?7702 1. <br /> NEAREST CROSS STREET 4o1. FACILITY OWNER TYPE ❑4.LOCAL AGENCY/DISTRICT* 402. <br /> I-205 Z 1.CORPORATION ❑5.COUNTY AGENCY* <br /> BUSINESS Z 1.GAS STATION ❑3.FARM ❑5.COMMERCIAL 403. ❑2.INDIVIDUAL ❑6.STATE AGENCY* <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR ❑6.OTHER ❑3.PARTNERSHIP ❑7.FEDERAL AGENCY* <br /> TOTAL NUMBER OF TANKS 404. Is facility on Indian Reservation 405. *If owner of UST is a public agency: name of supervisor of division, section or 406. <br /> REMAINING AT SITE or trust lands? office which operates the UST. (This is the contact person for the lank records.) <br /> 4 ❑Yes Z No N/A <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407• PHONE 408. <br /> E uilon Enterprises,LLC C/O Bruce T. Marubashi,Permit Analyst 925 766-3498 <br /> MAILING OR STREET ADDRESS 409. <br /> P.O. Box 8509 <br /> CITY 410. STATE 411. ZIP CODE 412. <br /> San Jose I CA 95155 <br /> PROPERTY OWNER TYPE Z 1.CORPORATION ❑2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT [:16.STATE AGENCY 413. <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415, <br /> E uilon Enterprises,LLC C/O Bruce T. Marubashi,Permit Analyst (925)766-3498 <br /> MAILING OR STREET ADDRESS 416. <br /> P.O. Box 8509 <br /> CITY 417. STATE 418. ZIP CODE _ 419• <br /> San Jose CA 95155 <br /> TANK OWNER TYPE Z 1.CORPORATION ❑2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 420. <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY TK HQ 44- T-O-F-3-T-91 0 1 2 1 6 1 Call 916 322-9669 if questions arise 421. <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ® 1.SELF-INSURED ❑4.SURETY BOND [17.STATE FUND ❑ 10.LOCAL GOVT MECHANISM 42. <br /> [12.GUARANTEE ❑5.LETTER OF CREDIT ❑8.STATE FUND&CFO LETTER ❑99.OTHER: <br /> [13.INSURANCE ❑6.EXEMPTION [19.STATE FUND&CD <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one box to indicate which address should be used for legal notifications and mailing. <br /> Legal notifications and mailings will be sent to the tank owner unless box 1 or 2 is checked. Z 1.FACILITY ❑2. PROPERTY OWNER ❑3.TANK OWNER 423. <br /> VII.APPLICANT SIGNATURE <br /> Certification: I certify that the information pr ided here' i rue and accurate to the best of my knowledge. <br /> SIGN URE OFL I NT DATE 424• PHONE 425. <br /> ti � /•� ` (707)789-3255 <br /> NAME OF APPLICANT(print) 426• TITLE 7 F APPLICANT 427. <br /> Tom Piskor(Agent for Equilon Ente rise ,LLC) Design Development Manager <br /> STATE UST FACILITY NUMBER(Agency use only) 428. 1998 UPGRADE CERTIFICATE NUMBER(Agency use only) 429• <br /> (See Data Element 1,above. <br /> UPCF Hwfwrc-a(1/99)-1/2 http://www.unidocs.org Rev.02/16/00 <br />