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IHE-D PROGRAM CONSOLIDATED LSI o TANKS UNDERGROUND STORAGE TANKS - FACILITY (one page per site) Page_of_- TYPE OF ACTION ❑ I.NEW SITE PERMIT ❑3.RENEWAL PERMIT ®5.CHANGE of INFORMATION ❑ 7.PERMANENTLY CLOSED SITE (Check one item only) ❑4.AMENDED PERMIT specify change local use only ❑ S.TANK REMOVED ❑&TEMPORARY SITE CLOSURE 400 i I. FACILITY /SITE INFORMATION BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As 3 1 FACILITY ID# [Tj I (,!SA GASOLINE #3696 ADDRESS 401 FACILITY OWNER TYPE ❑4.LOCAL GENCYIDISTRICT* 2.148 W. KETTLEMAN LANE,LODI, CA 95242 ® 1.CORPORATI( N ❑5.COUNTY AGENCY* ` RUSINrSS Z 1.GAS STATION [13.FARM ❑5. COMMERCIAL ❑ 2.INDIVIDUAL ❑6.STATE AGENCY* j 'TY PE ❑2.DISTRIBUTOR ❑4.PROCESSOR❑6. OTHER 403 ❑ 3.PARTNERSHIP [17.FEDERAL AGENCY* 402 ro 1'AL NUMBER OF TANKS Is facility on Indian Reservation or *Ifowner of UST is a public agency:name of supervisor of division,section or office which REMAIN[NO AT SITE trustlands? operates the UST(This is the contact person for the tank records.) I i 404 ❑ Yes ® No 405 406 II. PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407 PHONE 408 GREEN VALLEY GASOLINE LLC 818/865-9200 MAILING OR STREET ADDRESS 4N 30101 AGOURA CT. FCITY d10 SPATE 411 ZIP CODE n: I AGOURA HILLS CA i 91301 PROPERTY OWNER TYPE 1.CORPORATION D 2.INDIVIDUAL 0 4.LOCAL AGENCY/DISTRICT 0 6.STATE AGENCY ❑3.PARTNERSHIP [15.COUNTY AGENCY ❑7.FEDERAL AGENCY 413 M. TANK OWNER INFORMATION r L.yNK OWNER NAME 314 PHONE 41, USA PETROLEUM CORPORATION 818/865-9200 \CUl,TNG,OR STREET ADDRESS 41(, 31)101. AGOURA CT., SU200 Cr y - ITE 41'. STATE 418 ZIP CODE 414 ACrOURA HILLS CA 91301 _ "IAIvKi1WNERTYPE ® 1.CORYORA'iION ❑2.INDIViDIJAL, ❑4.LOCAL AGENCY i DISTRICT ❑6.S1'.4TE.ACiENCY tlo� ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL-AGENC" IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY (TK; 12 10 4 16 1 Call (916)322-9669 if questions arise 421 i V. PETROLEUM UST FINANCIAL RESPONSIBILITY ` )NDICA11-MF'I'HOD(s) ® L SELF-INSURED ❑4.SURETY BOND -t7 7. STATE FUND - ❑ 10.LOCAL uov'T MFCilAN13M ❑2.GUARANTEE ❑5.LE'11'ER OF CREDIT C 8•STATE FUND&CFO LETTER ❑ 99.OTHER: ❑3. INSURANCI' [3 6.ENEMPTION ❑9.STATE FUND&CD 422 VI. LEGAL NOTIFICATION AND MAILING ADDRESS arecl.onr,b: rr,rmi rate which address should hee u.cJ for yal notifications and marling -� L,-Gal noriftim.itms and marbngs will be sent to the tank owner unless box I or 2 is checl.ed ❑ 1.FACR.rTY I]2. PRt?PRR'rY i)WNF.R ®3 I'ANK!'.W1,4:R 4J VII. APPLICANT SIGNATURE ^ _._-.____.�.-.- thr•tttmnivrm4notrr*�d�**4orneniis-trmr4nu-nccut+tterrmevest-otmv�:netvteape- - ---- - -- _------ - 51GNATUR.E OF �PPL:IC.ANT �T , r '~DATE - ------`�a24 i PHONE n5 _ / i 01/03/03 � 818/86 -9200 NAME OF APPLICANT(print) 420 TITLE OF APPLICANT JOHN J. ZISK OPERATIONS MANAGER FACILITY NUMBER wF,r local use only) 428 i 1998 UPGRADE CERTIFICATE NUMBER(For local wseordy) 129 UPCF 1 1/99 revised) Formeriv SWRCB Form A,