COMPLIANCE INFO_1995-2007 - Laserfiche WebLink

Home Browse Search

0 IFIED PROGRAM CONSOLIDATED FORMZ�� G PR#:PR0506004 -7FAC#:FA0007140 UNDERGROUND STORAGE TANKS -FACILITY w (one page s ? , 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 6437 W BANNER ST,LODI BUSINESS NAME(Same as FACILITY NAME m DBA-Doing Business As) 31 FACILITY ID# PR ID# FLAG CITY SHELL �3 7 W � `� FA0007140 PRO506004 NEAREST CROSS STREET FACILITY OWNER TYPE 401 ❑ 4.LOCAL AGENCY/DISTRICT* BANNER f 1.CORPORATION ❑ 5.COUNTY AGENCY* BUSINESS ® 1 GAS STATION ❑ 3.FARM ❑ 5.COMMERCIAL 2.INDIVIDUAL 6.STATE AGENCY* TYPE ❑ ❑ 2.DISTRIBUTOR E] 4.PROCESSOR E] 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 office which operates REMAINING AT SITE trustlands? the UST(This is the contact person for the tank records.) 404 El Yes ® No 405NEW WEST PETROLEUM aob II.PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407 PHONE aos NEW WEST PETROLEUM MAILING OR STREET ADDRESS 409 1831 16TH ST CITY 410 1 STATE 411 ZIP CODE 412 SACRAMENTO CA 1 95814 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 414 PHONE ats NEW WEST PETROLEUM MAILING OR STREET ADDRESS 416 1831 16TH ST CITY 417 rTATE 418 PZIP CODE 419 SACRAMENTO CA 195814 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- F I 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 t.1 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 OF APPLIC. TDATE 424 PHONE a25 '711 q((v-443_OkgDA lad NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 427 - 1 u Le t> v- STATE UST FACILITY NUMBER(Forimi ue o*) 428 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 Is 1998 Compliant?Y UPCF(1/99 revised)