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UNIFIED PROGRAM CONSOLIDATED RM Dec <br /> UNDERGROUND STORAGE TANKS FACILITY� \ TANKS <br /> TYPE OF ACTION ❑ I.NEW SITE PERMIT (ono page per site) Page-of_ <br /> ❑3.RENS WAL PERMT ®S.CIiANGE OF INFORMATION <br /> (Ch<ck no item only) ❑3,AMENDED PERMIT P fy L1 7.PERMANENrLY CL03ED SITE <br /> a ed change local use only ❑ g,TANK REMOVED <br /> ❑fi.TEMPORAR(SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION aao <br /> BISINESS NAME(S,me ax FACILITY NAME or DBA-Doing Business As) 7 FACILITY ID# <br /> USA GASOLINE#3756 <br /> ADDRESS: I <br /> l 1975 E HIGHWAY 88,LOCKEFORD, CA 95237 eot FACILITY OWNER TYPE 4.LOCAL GENCY DISTRICT• <br /> BUSINF,ss 1.GAS STATION 3,FARM' ® 1.CORPORATION ❑5.COUNTY AGENCY4 <br /> �TYPF' 5. COMMERCIAL ❑ 2.INDIVIDUAL <br /> ❑2 DISTRIBUTOR ❑4.PROCESSOR❑6. OTHER ❑6.STATE AGENCY' <br /> PUl"-L!_]'UMBER OF TANKS 4m ❑ 9. PARTNERSHIP ❑7. FEDERAL AGENCY" <br /> Is facility on Indian Reservation or 9fowner of(fST is a public agency name of supenisor of iiviaioq aernon or olrce which <br /> REAP MINING.4T SITE trustlands7 <br /> 40e Yes ® No 45oPentes the UST(Thu u th<contact person Cor the tw*mcoras) <br /> ❑ <br /> eon <br /> IT. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME <br /> USA PETROLEUM CORPORATION 107 PHONE 408 <br /> MAILING OR STREET ADDRESS 818/865-9200 <br /> 30101 AGO CT, 409 <br /> CITY <br /> AGOURAHILLS 410 STATE ul Z[PCODE <br /> CA etz <br /> FR 5j OWNER TYPE I.WRPt RATION 2.INDIVIDUAL 4.LOCAL AGENCY,DISTRICT 6.STATE AGENCY <br /> ❑3.PARTNERSHIP 115.COUNTY AGENCY ❑7.FEDERAL AGENCY 4U <br /> III• TANK OWNER INFORMATION <br /> TANK OWNERNAME <br /> USA PETROLEUM CORPORATION $14 PHONE <br /> ad <br /> M,uLINt)OR RTREETADDRESS $1$/865-9200 <br /> 130101 AGOURA CT., SUITE 200 411, <br /> CIT) -- <br /> A60L"RA HILLS 'tv STATE ns LIP CODE <br /> CA av <br /> TANKiyWNER TYPE ® 1 CORPORATION 2 INDIVIDUAL 91301 <br /> ❑4 LOCAL A(rENCY. DISTRICT ii STATE AGENCY 0, <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7 FEDERAL.AGENC)' <br /> IV. BOARD OF EQUALIZATION USP STORAGE FEE ACCOUNT NUMBER <br /> TY H 14- 4 2 0 q 6 <br /> Call 916 322-9669 if uestlons arse - <br /> m11 <br /> _ V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INOR ATE MEiHOD(s) ® 1. SELFdNSCIRED ❑4,SURETY BOND - <br /> ❑2. GUARANTEE ❑Z STATE FUND ❑ lo,1,f1C.U..GOVT MECHANISM <br /> ❑5.LETTER OF CREDIT ❑8.STATE Ft IND&CFO LF17ER ❑ 99. <br /> ❑3. INSUR,4NCTi ❑t EXEMPFION ❑9. STATE FUND&CU OTHER. <br /> VI. LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Le8 <br /> oheek one has le-1-T-W which add-»shn,dd be used for legal notificalians and mailinG. --'--- - <br /> 4 rnu>icahnm and mmnngs w n be mm to the tank owner Op a bon I or 2 u the<k W. --•_ ----_- <br /> V--.-.-_..__ _..._ ❑ FACILITY 02. PROPERTY OWNER 03. 1A1-+K:,WNER +27 <br /> - VII, APPLICANT SIGNATURE - <br /> .-_ r-Iwr .vU.alhe„Uurmsunn prov,netr me,oiil+u<nndaccurate[:ih<besl.v ms knowledge --------"--'-'- <br /> SIGNATURE O)•APPLICANT ' <br /> DATE 414 PHONE ­-_ azs <br /> NAME OF APPLICANT(pnn0 01/03/0.- 818/865-9200 <br /> 12pTITLE OF.APPLICANT <br /> ' <br /> JOHN J. ZISK OPERATIONS MANAGER 1 <br /> STATE US'r FACILITY NUMBER(F.,wait ussmdy) i+g <br /> 1998 UPGRADE CERTiFICa'iE NUMBER mor Wcal ass m,lY1 � a2y <br /> I <br /> UPCF(1/99 revised) <br /> Formerly SWRC3 Frim A <br />