COMPLIANCE INFO - Laserfiche WebLink

Home Browse Search

IFIED PROGRAM CONSOLIDATED FO PR#:PR0231833 A� 0 O ( FAC#:FA0003874 UNDERGROUND STORAGE TANKS -FACILIT ` �te f �S\° o� I I03 15� (one page per 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 ❑ 8.TANK REMOVED 1:16.TEMPORARY SITE CLOSURE 400 I.FACILITY/SITE INFORMATION 6970 WEST LN 130,STOCKTON BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) g FACILITY ID# I PR ID# TT ECONO LUBE N TUNE FA0003874 PR0231833 1 NEAREST CROSS STREET FACILITY OWNER TYPE ❑ 4.LOCAL AGENCY/DISTRICT• WEST n01 ❑ 1.CORPORATION ❑ 5.COUNTY AGENCY* BUSINESS ❑ 1.GAS STATION ❑ 3.FARM M 5.COMMERCIAL ❑ 2.INDIVIDUAL ❑6.STATE AGENCY* TYPE ❑ 3.PARTNERSHIP 402 ❑ 2.DISTRIBUTOR ❑ 4.PROCESSOR ❑6.OTHER 403 E37.FEDERAL AGENCY* 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 which operates REMAINING AT SITE trustlands? the UST(This is the contact person for the tank records.) 404 ❑ Yes ® No 405 406 II.PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407 PHONE 408 714 851-2259 MAILING OR STREET ADDRESS 409 4911 BIRCH ST CITY 410 STATE 411 ZIP CODE 412 NEWPORT BEACH CA 92658 PROPERTY OWNER TYPE ® 1.CORPORATION ❑ 2.INDIVIDUAL ❑ 4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY ❑3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY 413 III.TANK OWNER INFORMATION TANK OWNER NAME � -�+ * 1 414 PHONE - 415 R0�q0& 1 L G L(t W 209 i MAILING OR STREET ADDRESS �I 10 `,, `tT � - w alb 1 b wVJ CITY / 417 STATE 418 ZIP CODE 419 S �W�N CA 19520 GO TANK OWNER TYPE ❑ 1 CORPORATION .INDIVIDUAL ❑ 4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY 420 ❑ 3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY .t IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY(TK)HQ 44- 1 Call(916)322-9669 if questions arise 421 V.PETROLEUM UST FINANCIAL RESPONSIBILITY INDICATE METHOD(s) ❑ 1.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 mailing. ® 1.FACILITY ❑2.PROPERTY OWNER ❑3.TANK OWNER 423 Legal notifications and mailing will be sent to the tank owner unless box I or 2 is checked. VII.APPLICANT SIGNATURE Certi do -I certify that the information pro 'ded herein is true and accurate to the best of my knowledge. SIGT AP C DA 424 HONE NPE PLIC T(print) 426 TITLE OF APPLICANT 427 0 L STATE UST FACILITY NUMBER(For local ue only) 428 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 Is 1998 Compliant?N UPCF(1/99 revised)