COMPLIANCE INFO_2003-2010 - Laserfiche WebLink

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a� RNFIFIED PROGRAM CONSOLIDATED FOR y' PR#: 31554 FA :FA0005678 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 e I.FACILITY/SITE INFORMATION 16500 E LOUISE AVE,LATHROP BUSINESS NAME(same as FACILITY NAME or DBA-Doing Business As) g FACILITY ID# PR'M*#2611195 /✓4C)611 7 6 FA0005678 PR0231554 1 NEAREST CROSS STREET FACILITY OWNER TYPE E]401 4.LOCAL AGENCY/DISTRICT' Jeipwlj�*_ nt ❑ 1.CORPORATION ❑ 5.COUNTY AGENCY' BUSINESS 21�1,GAS STATION ❑ 3.FARM ❑ 5.COMMERCIAL 2r2.INDIVIDUAL ❑ 6.STATE AGENCY' TYPE ❑ ❑ [:] [_1 3.PARTNERSHIP 402 2.DISTRIBUTOR 4.PROCESSOR 6.OTHER a03 ❑ 7.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.) 11 2 404 El Yes ® No aos NASSER ARBABIA N �✓t c�. � 4n 406 II.PROPERTY OWNER INFORMATION PROPERTY OWNER NAME _ 407 PHONE(_2Gq 9 8 3 T 03 S Vo8 MAILING OR STREET ADDRESS 409 s of 69o .f) CITY S I J. STATE (74 all ZIP CODE 1s Z G 9_�S.i 4 412 � P C k o.^ 410 850;2 PROPERTY OWNER TYPE ❑ 1.CORPORATION 2r2.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 415 c'61ATac-OPi31LLi S fT A ALY S''`_ f9211 2 - 4 MAILING OR STREET ADDRESS 416 PTrMTX 52085 CITY 4,7 STATE 418 ZIP CODE 419 _PHOE+IflI A &50:72-2495 TANK OWNER TYPE ❑ 1.CORPORATION 2.INDIVIDUAL 1:14.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- -4zCall(916)322-9669 if questions arise 421 -(9 ETROLEUM UST FINANCIAL RESPONSIBILITY INDICATE METHOD(s) ❑ 1.SELF-INSURED ❑4.SURETY BOND a-7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM ❑2.GUARANTEE ❑ 5.LETTER OF CREDIT ❑ 8.STATE FUND&CFO LETTER ❑99.OTHER 0 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 }Q 1.PROPERTY OWNER ❑3.TANK OWNER a23 Legal notifications and mailing will be sent to the tank owner unless box 1 or 2 is checked. VII.APPLICANT SIGNATURE Certification-1 certify that the information provided herein is true and accurate to the best of my knowledge. ' SIGNATURE OF APPLICANT DATE ata PHONE `.s 9� 967-0-38t, 2/17 J2.W S_ NAME OF APPLICANT(print) ) ) L 126 TITLE OF APPLICANT 427 STATE UST FACILITY NUMBER(For local=only) 428 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 Is 1998 Compliant?Y UPCF(1/99 revised)