COMPLIANCE INFO_1997-2006 - Laserfiche WebLink

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U IED PROGRAM CONSOLIDATED M TANKS I UNDERGROUND STORAGE TANKS - FACILITY (one page per site) Page _ of _ TYPE OF ACTION ❑1.NEW SITE PERMIT ❑3.RENEWAL PERMIT ®5.CHANGE OF INFORMATION(Specify change- ❑7.PERMANENTLY CLOSED SITE (Check one item only) 1714.AMENDED PERMIT local use only) ❑8.TANK REMOVED 400 ❑6.TEMPORARY SITE CLOSURE I.FACILITY I SITE INFORMATION BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 FACILITY ID# 1 ConocoPhillips Company#255417 BUSINESS SITE ADDRESS 401 FACILITY OWNER TYPE 4. LOCAL AGENCY/DISTRICT* 1700 EAST YOSEMITE AVE ® 1. CORPORATION 5. COUNTY AGENCY* 2. INDIVIDUAL 6. STATE AGENCY* BUSINESS TYPE ®1.GAS STATION ❑ 3.FARM ❑5.COMMERCIAL 3. PARTNERSHIP 7. FEDERAL AGENCY* 402 ❑2.DISTRIBUTOR ❑ 4.PROCESSOR ❑ 6.OTHER 403 TOTAL NUMBER OF TANKS Is facility on Indian Reservation or *If owner of UST is a public agency:name of supervisor of REMAINING AT SITE trustlands? division,section or office which operates the UST. (This is the contact person for the tank records.) 2 404 ❑Yes ®No 405 406 11.PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407 PHONE 408 ConocoPhillips Company 1 (281) 293-1000 MAILING OR STREET ADDRESS 409 600 North Dairy Ashford Dr. CITY 410 STATE 411 ZIP CODE 412 Houston TX 77079 PROPERTY OWNER TYPE ❑ 2. INDIVIDUAL ❑ 4. LOCAL AGENCY/DISTRICT ❑ 6. STATE AGENCY 413 ❑ 1. CORPORATION ❑ 3. PARTNERSHIP ❑ 5. COUNTY AGENCY ❑ 7. FEDERAL AGENCY III.TANK OWNER INFORMATION TANK OWNER NAME 414 PHONE 415 ConocoPhillips Company-Atttn.: Retail Marketing, Licenses & Permits 1 (281) 293-5101 MAILING OR STREET ADDRESS 416 600 North Dairy Ashford Dr. CITY 417 STATE 418 ZIP CODE 419 HOUSTON TX 77079 TANK OWNER TYPE 2. 4. LOCAL AGENCY/® STATEAENCY 1. CORPORATION H3. ARITNE SHIP 5. OUNTYAG NCYDISTRICT H 6 7. FEDERALGAGENCY 0 IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TYMT Ll 4 1 4 M- O 4 1 1 9 9 8 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 GOV=T MECHANISM ❑ 2. GUARANTEE ❑ 5. LETTER OF CREDIT ❑ 8. STATE FUND&CFO LETTER 99. OTHER: 422 03. INSURANCE ❑ 6. EXEMPTION ❑ 9. STATE FUND&CD 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 mailings 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. SIGNATUR:OF APPLICANT DATE 424 PHONE 425 _ ® (510) 245-5218 NAME OF APPLICANT(print) TITLE OF APPLICANT 426 Julie Lee HSE Specialist STATE UST FACILITY NUMBER(For local use only) 427 1 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 428 UPCF(1/99 revised) 5 Formerly SWRCB Form A