BILLING 1999 - 2005 - Laserfiche WebLink

Home Browse Search

1FIED PROGRAM CONSOLIDATED FO - N I I� , PR#:PRV45151 �• FAC#:FA000781 KS UNDERGROUND STORAGE TAN - ACI (one page per site) TYPE OF ACTION ❑ I.NEW SITE PERMIT ❑3.RENEWALPERMIT ❑ 5.CHAN(IE OF[NJ ORMATION ].PERMANENTLY CLOSED SITE (Check one item only) ❑4,AMENDED PERMIT e}w.+q cEmge local tuamdy ❑ 8.TANK REMOVED ❑6.TEMPORARY SITE CLOSCRF 400 L FACILITY/SITE INFORMATION 707 E YOSEMITE AVE.MANTECA BUSINESS NAME(Same.FACILITY NAME or DBA-Dau�g Business As) 3 FACILITY ION PR ID# PONTES VICKI-KLEEN CAR=, FA0007815 PR0505151 NEAREST CROSS STREET FACILITY OWNER TYPE ❑q.LOCAL AGENCY/DISTRICT• YOSEMITE 401 ❑ 1.CORPORATION ❑ 5.COUNTY AGENCY• BUSINESSE:12.INDIVIDUAL ® 1.GAS STATION ❑ 3.FARM ❑ 5.COMMERCIAL ❑ 3 PARTNERSHIP El 6.STATE AGENCY- TYPE ❑ 2.DISTRIBUTOR ❑ 4.PROCESSOR r-16.OTHER 403 ❑ 7.FEDERAL AGENCY• 402 TOTAL NUMBER OF TANKS Is facility on Indian Reservation or *If owner of UST is a public agency:name ofsupervisor ofdivision,section or office which operates REMAINING AT SITE trustlands? the UST(This is she contact person for the tank records.) +04 ❑ Yes ®No 405 nos 11.PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407 P14ONE40e PONTES LAURINO E&M L (209) 209 823-9159 MAILING OR STREET ADDRESS 409 19441 SUTCLIFF AVE clTv 419 sTATe411 ZIPCODE 412ESCALON CA 95320 PROPERTY OWNER TYPE ® I.CORPORATION ❑ 2.INDIVIDUAL ❑ 4.LOCAL AGENCY/DISTRICT 116.STATE AGENCY ❑3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY 413 III.TANK OWNER INFORMATION 7ANKOWNERNAME ala PHONE 41s PONTES LAURINO E&M L 209 823-9159 MAILING OR STREET ADDRESS 416 19441 SUTCLIFF AVE CITY all 1 STATE418 ZIPCODE 419 ESCALON CA 95320 TANK OWNER TYPE ❑X 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) ❑ I.SELF-INSURED ❑4.SURETY BOND ❑ 7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM ❑2.GUARANTEE ❑5.LETTER OF CREDIT ❑ 8.STATE FUND&CFO LETTER X❑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 nailing. M 1.FACILITY ❑2.PROPERTY OWNER ❑3.TANK OWNER 4n Legal notifications and maifing will be sent to the tank owner unless box 1 or 2 is checked. VII.APPLICANT SIGNATURE Certification-1 certify Nat the information provided herein is me and accurate to the best of my knowledge. SIGNATURE OF APPLICANT DATE 424 PHONE 425 NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 427 STATE UST FACILITY NUMBER(Fwml ec may) 428 1998 UPGRADE CERTIFICATE NUMBER(Fmlocalusconry) 429 Is 1998 Compliant?Y UPCF(1/99 revised)