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NIFIED PROGRAM CONSOLIDATED Fam r I TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY v) �t '4gji <br /> �r <br /> (one page per site) Page_of <br /> TYPE OF ACTION ❑ 1.NEW SITE PERMIT ®3.RENEWAL PERMIT .CHANGE OF INFORMATION ❑ 7.PERMANENTLV CLOSED SITE <br /> (Check one item only) ❑4.AMENDED PERMIT ecify change local use only ❑ B.TANK REMOVED 400 <br /> ❑&TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Semeas FACILITY NAME or DBA-Doing Business As) 3 FACILITY ID# t <br /> Valero Corner Store #3698 I 6T' 401 FACILITY OWNER TYPE ❑4. LOCAL GENCY/DISTRICT' <br /> NEAREST CROSS STREET <br /> ® 1.CORPORATION [15.COUNTY AGENCY' <br /> 6.STATE AGENCY' <br /> BUSINESS 1.GAS STATION 3.FARM 5. COMMERCIAL ❑ 2.INDIVIDUAL ❑7 FEDERAL AGENCY` 402 <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR❑6. OTHER 403 ❑ 3. PARTNERSHIP ❑ <br /> 'If owner of UST is a public agency:name of supervisor of division,section or office <br /> TOTAL NUMBER IT TANKS Is facility on Indian Reservation or which operates the UST(This is the contact person for the tank records.) <br /> REMAINING AT SITE frustlands? 406 <br /> 3 404 ❑ Yes ® No 405 <br /> IL PROPERTY OWNER INFORMATION <br /> 4w PHONE 408 <br /> PROPERTY <br /> OWNER NAME 559-582-0241 <br /> Valero California Retail Company 409 <br /> MAILING OR STREET ADDRESS <br /> 685 W. Third St. 410 STATE 411 ZIP CODE 412 <br /> CITY 93230 <br /> Hanford CASTATE <br /> PROPERTY OWNER TYPE ® 1.CORPORATION 2.❑3.PARIVIDUAL Lj 4.TNERSHIP ❑5.COOUNTY AGENCYDISTRICT ❑8. FEDERAGENCY 413 <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME <br /> 414 PHONE 415 <br /> Valero California Retail Company 559-562-0241 <br /> ats <br /> MAILING OR STREET ADDRESS <br /> 685 W Third Street 419 <br /> CITY 4n STATE ate ZIP CODE <br /> H2. IND <br /> tEA <br /> fd CA 93230-5000 <br /> R TYPE ® 1. CORPORATION ❑❑3. PARTNERSHIP ❑5.COUNTY AGENCYDISTRICT ❑Ll 67.. FEDERAL AGENCY 420 <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> Q 44- 2 4 6 6 0 <br /> Call 916 322-9669 if questions arise 421 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> ® 1.SELF-INSURED ❑4.SURETY BOND ❑7.STATE FUND10. LOCAL GOVT MECHANISM <br /> ❑2.GUARANTEE ❑5. LETTER OF CREDIT ❑6.STATE FUND&CFO LETTER ❑ 99.OTHER: 422 <br /> ❑3. INSURANCE ❑6.EXEMPTION ❑9.STATE FUND&CDVI. LEGAL NOTIFICATION AND MAILING ADDRESS <br /> x to indicate which address should be used for legal notifications and mailing. <br /> tions antl mailings will be sent to the tank owner unless box 1 or 2 is checked. ❑ 1.FACILITY [12. PROPERTY OWNER ®3.TANK 423 <br /> OWNER <br /> VII. APPLICANT SIGNATURE <br /> Certification-I certify that the information provided herein Is true and accurate to the best of my knowledge. 425 <br /> SIGNATURE OF APPLIC 1 i DATE 424 PHONE <br /> Iq 0 7 559-583-3298 <br /> NAME OF APPLICANT(print) U <br /> 42s TITLE OF APPLICANT 427 <br /> Sandy Huff Operations & Environmental Specialist <br /> STATE LIST FACILITY NUMBER(For local use only) <br /> 428 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 425 <br /> UPCF(1/99 revised) Formerly SWRCB Form A <br />