Laserfiche WebLink
` D PROGRAM CONSOLIDATED FORM* -7 Zit U Z PR I:PRO506004 <br /> FAC I:FA0007140 <br /> UNDERGROUND STORAGE TANKS -FACILITY <br /> 0� a? <br /> (one page p s <br /> TYPE OF ACTION ❑ 1.NEW SITE PERMIT ❑3.RENEWAL PERMIT 5.CHANGE OF INFORMATION ❑ 7.PERMANENTLY CLOSED SITE <br /> (Check one noun only) ❑4.AMENDED PERMIT ❑ 8.TANK REMOVED <br /> ❑6.TEMPORARY SITE CLOSURE 400 <br /> I.FACILITY/SITE INFORMATION 6437 W BANNER ST.LODI <br /> BUSINESS NAME(a.a,FACILITY NAsfS ar DBA-Dole,Bggshma A.) 3 FACILITY IDI FR 1114 <br /> FLAG CITY SHELL to N 3 7 W '✓ �a�' FA0007140 PR0506004 <br /> NEAREST CROSS STREET FACILITY OWNER TYPE <br /> 401 ❑ 4.LOCAL AGENCY/DISTRICT- <br /> BANNER 1.CORPORATION ❑ 5.COUNTY AGENCY- <br /> BUSINESS ® 1.GAS STATION ❑ 3.FARM ❑ S.COMMERCIAL ❑ 2.INDIVIDUAL ❑ 6.STATE AGENCY- <br /> TYPE ❑ 2.DISTRIBUTOR ❑4.PROCESSOR ❑ 6.OTHER 403 ❑ 3.PARTNERSHIP ❑ 7.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 ofdivisim,section or oRlce which operates <br /> REMAINING AT SITE Intsllands? the UST(This is the contact Person for the tank records.) <br /> eon ❑ Yes ® No 005 NEW WEST PETROLEUM 906 <br /> IL PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408 <br /> NEW WEST PETROLEUM <br /> MAILING OR STREET ADDRESS <br /> 409 <br /> 1831 16TH ST <br /> CITY 410 STATE 411 ZIP CODE 412 <br /> SACRAMENTO I CA 95814 <br /> PROPERTY OWNER TYPE ® l.CORPORATION ❑ 2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY <br /> ❑3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑7.FEDERAL AGENCY 413 <br /> M.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> NEW WEST PETROLEUM <br /> MAILING OR STREET ADDRESS <br /> 416 <br /> 1831 16TH ST <br /> CITY - 417 STATE418 ZIPCODE d19 <br /> SACRAMENTO CA 95814 <br /> TANK OWNER TYPE OI.CORPORATION 02.INDIVIDUAL El 4.LOCAL AGENCY/DISTRICT L1 6.STATE AGENCY 420 <br /> ❑ 3.PARTNERSHIP ❑5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 1 Call(916)322-9669 if questions arise 421 <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ❑ 1.SELF-INSURED 1:14.SURETY BOND ❑ 7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM <br /> ❑2.GUARANTEE ❑5.LETTER OF CREDIT 8.STATE FUND&CFO LETTER t 1 99.OTHER <br /> ❑3.INSURANCE ❑6.EXEMPTION ❑ 9.STATE FUND&CD 422 <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one box to indicate which address should be used for legal notifications and mailing. ® 1.FACILITY ❑2.PROPERTY OWNER ❑3.TANK OWNER 423 <br /> Legal notifications and mailing will be sent to the tank owner unless box I or 2 is checked. <br /> VII.APPLICANT SIGNATURE <br /> Certification-I certify that the inforrrlation provided herein is one and accurate to the best ofmy knowledge. <br /> SIGNATURE OF APPLIC DATE 424PHONE as <br /> -7ftsIoa- Gly-��3-o axt-yl <br /> NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 427 <br /> Rt4lg' 1 -0-VA L tcL r <br /> STATE UST FACILITY NUMBER(For 1 .1 ae only) 428 1998 UPGRADE CERTIFICATE NUMBER(Fm lonl ere emy) 429 <br /> Is 1998 Compliant?Y <br /> UPCF(1/99 revised) <br />