Laserfiche WebLink
NIFIED PROGRAM CONSOLIDATED FISM TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page per site) Page_of_ <br /> TYPE OF ACTION ❑ 1.NEW SITE PERMIT ®3.RENEWAL PERMIT ❑S. GE OF INFORMATION ❑ TPERMANENTLY CLOSED SITE <br /> (Check one Item only) ❑4.AMENDED PERMIT specify,change local use only ❑ B.TANK REMOVED <br /> ❑6.TEMPORARY SITE CLOSURE 400 <br /> I. FACILITY/SITE INFORMATION <br /> BUSINESS NAME isamees FACILITY NAME or DBA-Doing Business As) 3 FACILITY ID# 1 <br /> Beacon Station#3698 <br /> NEAREST CROSS STREET 401 FACILITY OWNER TYPE ❑4.LOCAL GENCYIDISTRICT' <br /> ® 1.CORPORATION [15.COUNTY AGENCY- <br /> BUSINESS ®1.GAS STATION [13.FARM [15. COMMERCIAL ❑ 2.INDIVIDUAL ❑6.STATE AGENCY- <br /> TYPE ❑2.DISTRIBUTOR [0:14,PROCESSOR❑6. OTHER 403 ❑ 3.PARTNERSHIP [17.FEDERAL AGENCY- 402 <br /> 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 <br /> REMAINING AT SITE trustlands? which operates the UST(This is the contact person for the tank records.) <br /> 3 404 ❑ Yes ® No 405 406 <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 4oa <br /> Ultramar Inc 559-582-0241 <br /> 409 <br /> MAILING OR STREET ADDRESS <br /> 685 W. Third St. <br /> CITY 410 1 STATE 411 ZIP CODE 412 <br /> Hanford CA 93230 <br /> PROPERTY OWNER TYPE ® 1.CORPORATION ❑2.INDIVIDUAL ❑4.LOCALAGENCY/DISTRICT ❑6.STATE AGENCY <br /> ❑3.PARTNERSHIP [15.COUNTY AGENCY ❑7.FEDERAL 413 <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> Ultramar Inc. 559-582-0247 416 <br /> MAILING OR STREET ADDRESS <br /> 685 W Third Street 419 <br /> CITY 417 STATE 416 1 ZIP CODE <br /> Hanford CA 93230-5000 <br /> TANK OWNERTYPE 1.CORPORATION ❑2.INDIVIDUAL 4.LOCAL AGENCY/DISTRICT 6.STATE AGENCY azo <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY [17.FEDERAL AGENCY <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY TK HO 44- 2 4 6 6 0 <br /> Call 916 322-9669 if questions arise 421 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE ® 1.SELF-INSURED ❑4.SURETY BOND [17.STATE FUND ❑ 10.LOCAL GOVT MECHANISM <br /> METHOD(s) 1-12.GUARANTEE ❑5.LETTER OF CREDIT ❑8.STATE FUND&CFO LETTER ❑ 99.OTHER: 422 <br /> ❑3.INSURANCE ❑6.EXEMPTION ❑9.STATE FUND&CD <br /> VI. LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one box io indicate which address should be used for legal notifications and mailing. 423 <br /> Legal notifications and mailings will be sent to the lank owner unless box 1 or 2 is checked. ❑ 1.FACILITY ❑2. PROPERTY OWNER ®3.TANK <br /> OWNER <br /> VII. APPLICANT SIGNATURE <br /> Certification-I ceN tha Ne info a5on vided herein is true and accurate to the best of my knowledge. a25 <br /> SIGNAT P DATE 424 PHONE <br /> 1125102 559-583-3398 <br /> 427 <br /> NAME OF APPLICANT(print) 426 TITLE OF APPLICANT <br /> Dennis Smith I Operations & Environmental Specialist <br /> STATE UST FACILITY NUMBER(For Loral use only) 428 1998 UPGRADE CERTIFICATE NUMBER(Forloral use only) <br /> 429 <br /> UPCF(1199 revised) Formerly SWRCB Form A <br />