COMPLIANCE INFO_1998-2006 - Laserfiche WebLink

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IFIED PROGRAM CONSOLIDATED FORPR#:PR0231141 .qw Is FAC#:FA0003954 UNDERGROUND STORAGE TANKS -FACILITY (one page per site) TYPE OF ACTION ❑ 1.NEW SITE PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENTLY CLOSED SITE (Check one item only) 4.AMENDED PERMIT ❑ ❑ 8.TANK REMOVED ❑6.TEMPORARY SITE CLOSURE 400 I.FACILITY/SITE INFORMATION 1810 E HAZELTON AVE.STOCKTON BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Busimss As) g FACILITY ID# PR ID# SJ CO PUBLIC WORKS CORP YARD* FA0003954 PR0231141 1 NEAREST CROSS STREET FACILITY OWNER TYPE 401 ❑ 4.LOCAL AGENCY/DISTRICT* HAZELTON ❑ 1.CORPORATION ❑ 5.COUNTY AGENCY* BUSINESS ® 1.GAS STATION ❑ 3.FARM ❑ 5.COMMERCIAL ❑ 2.INDIVIDUAL * TYPE ❑ 6.STATE AGENCY ❑ 2.DISTRIBUTOR ❑ 4.PROCESSOR E] 6.OTHER 403 ❑ 3.PARTNERSHIP ❑ 7.FEDERAL AGENCY* 402 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 El No 405 406 IL PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407 PHONE 408 SAN JOA UIN PUBLIC WORKS 209 468-3106 MAILING OR STREET ADDRESS 409 PO BOX 1810 CITY 410 STATE 411 ZIP CODE 412 STOCKTON CA 1 95205 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 414 PHONE als SAN JOA UIN PUBLIC WORKS MAILING OR STREET ADDRESS 416 Po 50X IS to CITYATE 418 ZIP CODE 419 �7CA STOCKTON 95265 L16 2.0) TANK OWNER TYPE 1.CORPORATION ❑ 2.INDIVIDUAL ❑ 4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY 420 ❑ 3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY(TK)HQ 44- 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 1:12.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 1 or 2 is checked. VII.APPLICANT SIGNATURE Certification-I certify that the information provided herein is true and accurate to the best of my knowledge. SIGNATURE OF APPLICANT DATE 424 1 PHONE 425 NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 427 STATE UST FACILITY NUMBER(For tows w only) 428 1998 UPGRADE CERTIFICATE NUMBER(For local use onty) 429 Is 1998 Compliant?Y UPCF(1/99 revised)