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rr <br />FIED PROGRAM CONSOLIDATED FOP16 \I\ylQ, TANKS <br />9,&c _1' <br />UNDERGROUND STORAGE TANKS - FACILITY o\ <br />(one page per site) Page _ of <br />TYPE OF ACTION ❑ 1. NEW SITE PERMIT ® 3. RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ ].PERMANENTLY CLOSED SITE <br />(Check one Item only) ❑ 4. AMENDED PERMIT specify change local use only [18. TANK REMOVED <br />❑ 6 TEMPORARY SITE CLOSURE 400 <br />I. FACILITY /SITE INFORMATION <br />BUSINESS NAME Iseme as FACILITY NAME or 08A -Doing 9usiness As) 3 FACILITY It <br />Di O O O b ,� r 1 <br />Beacon Station #3492 <br />401 FACILITY OWNER TYPE 4. LOCAL DISTRICT' <br />NEAREST CROSS STREET AGENCY' <br />® 1. CORPORATION ❑ 5. COUNTY Y AGENCY - <br />BUSINESS ® 1. GAS STATION ❑ J. FARM ❑ 5. COMMERCIAL ❑ 2. INDIVIDUAL ❑ 6. STATE AGENCY - <br />BUSINESS <br />❑ 7. FEDERAL AGENCY' 402 <br />TYPE ❑ 2. DISTRIBUTOR [14. PROCESSOR ❑ 6. OTHER 403 ❑ 3. PARTNERSHIP <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 />the UST (This is the contact person for the tank records.) <br />REMAINING AT SITE trustlands? which operates <br />406 <br />2 404 ❑ Yes ® No 405 <br />IL PROPERTY OWNER INFORMATION <br />PROPERTY OWNER NAME 407 PHONE 408 <br />559-582-0241 <br />Ultramar Inc. 409 <br />MAILING OR STREET ADDRESS <br />685 W. Third St. 410 STATE 411 ZIP CODE 412 <br />CITY <br />1 CA 93230 <br />Hanford <br />PROPERTY OWNER TYPE ® 1. CORPORATION 712. INDIVIDUAL L]4. LOCAL AGENCY / DISTRICT LJ 6. STATE AGENCY <br />[:13. PARTNERSHIP ❑ 5. COUNTY AGENCY ❑ 7. FEDERAL 413 <br />111. TANK OWNER INFORMATION <br />TANK OWNER NAME 414 PHONE 415 <br />Ultramar Inc. 559-582-0241 <br />16 <br />MAILING OR STREET ADDRESS <br />685 W Third Street <br />STATE 416 ZIP CODE419 <br />CITY 417 <br />CA 93230-52C]TAFEDERALAGENCY <br />Hanford <br />TANK OWNER TYPE U T CORPORATION 2. INDIVIDUAL ❑ 4. LOCAL AGENCY / DISTRICY azo <br />❑ 3. PARTNERSHIP ❑ 5. COUNTY AGENCYENCYIV. <br />BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NTY <br />TK HQ 44- 2 4 6 6 0Call 916 322-9669 if uestion421V. <br />PETROLEUM UST FINANCIAL RESPONSIBILITY <br />INDICATE E 1. SELF-INSURED ❑ 4. SURETY BOND ❑7. STATE FUND ❑ 10. LOECHANISMMETHOD(s) <br />❑ 2. GUARANTEE ❑ 5. LETTER OF CREDIT ❑ 8. STATE FUND 8. CFO LETTER ❑ 99. OT422 <br />❑ 3. INSURANCE ❑ 6. EXEMPTION ❑ 9. STATE FUND & CO <br />VI. LEGAL NOTIFICATION AND MAILING ADDRESS <br />Check one box to indicate which address should be used for legal notifications and mailing.423 <br />be to the tank owner unless box 1 or 2 is checked. ❑ 1. FACILITY [j2. PROPERTY OWNER ® 3. TANK <br />Legal notifications and mailings will sent <br />OWNER <br />VII. APPLICANT SIGNATURE <br />Certification - I certi the the info lion p vi ed herein is true and accurate to the best of my knowledge. 425 <br />SIGNAT P I DATE 424 PHONE <br />1/3/02 559-583-3398 <br />427 <br />426 <br />NAME OF APPLICANT (print) <br />TITLE OFA"LICANT <br />Operations & Environmental Specialist <br />Dennis Smith <br />429 <br />429 <br />STATE UST FACILITY NUMBER (For local use only) <br />1998 UPGRADE CERTIFICATE NUMBER (Fa(locsi use only) <br />UPCF (1/99 revised) Formerly SWRCB Form A <br />