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ED PROGRAM CONSOLIDATED FO) <br /> UNDERGROU&D STORAGE TANKS - FACILITY T � <br /> (one page per site) <br /> TYPE OF ACTION ❑ I.NEW SITE PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENTLY CLOSE SIT <br /> (Check one item only) ❑ 4.AMENDED PERMIT ❑ 8.TANK REMOVED <br /> ❑6.TEMPORARY SITE CLOSURE <br /> I.FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 FACILITY ID# <br /> ECONO LUBE N TUNE FA0003874 ' <br /> NEAREST CROSS STREET FACILITY OWNER TYPE ❑4.LOCAL AGENCY/DISTRICT* <br /> aol <br /> WEST ❑ 1.CORPORATION ❑ 5.COUNTY AGENCY' <br /> BUSINESS ❑ 1.GAS STATION ❑ 3.FARM ❑ 5.COMMERCIAL ❑ 2.INDIVIDUAL ❑ 6.STATE AGENCY' <br /> TYPE ❑ 2.DISTRIBUTOR ❑ 4.PROCESSOR ❑ 6.OTHER 403 ❑3.PARTNERSHIP492 <br /> ❑ 7.FEDERAL AGENCY <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 whichY <br /> REMAINING AT SITE trustlands? operates the UST(This is the contact person for the tank records.) �7 <br /> 1 404 ElYes ®No aos "VC, <br /> II.PROPERTY OWNER INFORMATION JQ <br /> PROPERTY OWNER NAME 407 PHONE 408 <br /> 714 851-2259 <br /> MAILING OR STREET ADDRESS 409 <br /> 4911 BIRCH ST <br /> CITY 410 STATE 411ZIP CODE 412 <br /> NEWPORT BEACH CA 92658 <br /> PROPERTY OWNER TYPE ® 1.CORPORATION❑ 2.INDIVIDUAL ❑ 4.LOCAL AGENCY/DISTRICT 116.STATE AGENCY <br /> ❑3.PARTNERSHIP 1:15.COUNTY AGENCY 1:17.FEDERAL AGENCY 413 <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> ECONO LUBE N TUNE <br /> MAILING OR STREET ADDRESS 416 <br /> 6970 WEST LANE <br /> CITY 417 STATE418 1 ZIP CODE 419 <br /> STOCKTON CA 95210 <br /> TANK OWNER TYPE ❑ 1.CORPORATION 1:12.INDIVIDUAL 114.LOCAL AGENCY/DISTRICT 116.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- Call 916 322-9669 if questions arise 421 <br /> ,. <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ❑ 1.SELF-INSURED ❑4.SURETY BOND ❑ 7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM <br /> ❑2.GUARANTEE 1:15.LETTER OF CREDIT❑ 8.STATE FUND&CFO LETTER❑9 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 information provided herein is true and accurate to the best of my knowledge. <br /> SIGNATURE OF APPLICANT DATE 424 1 PHONE 425 <br /> NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 427 <br /> STATE UST FACILITY NUMBER(For bcal ue only) 428 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 <br /> N <br /> UPCF(1/99 revise <br />