COMPLIANCE INFO_2001-2009 - Laserfiche WebLink

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JNIFIED PROGRAM CONSOLIDATED FOR R#:PR0231691 ! �.n n F C 7�1�� 593 UNDERGROUND STORAGE TANKS -FACILITY,,,>` f Ir HEAL I TYPE OF ACTION ❑ 1.NEW SITE PERMIT 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION7.PERMANENTLY CLOSED§ITE�K (Check one item only) ❑ 4,AMENDED PERMIT HUNISEEMM 08t919DVP F-16.TEMPORARY SITE CLOSURE �* 4� I.FACILITY/SITE INFORMATION 983 MOFFAT BLVD,MANTECA QGo r BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 FACILITY ID# PR ID# OLYMPIAN FA0003593 PR0231691 1 NEAREST CROSS STREET FACILITY OWNER TYPE ❑ 4.LOCAL AGENCY/DISTRICT* MOFFAT 401 M 1.CORPORATION ❑ 5.COUNTY AGENCY* BUSINESSEl2.INDIVIDUAL E] 6.STATE AGENCY* 1.GAS STATION ❑ 3.FARM ❑ 5.COMMERCIAL TYPE E] 3.PARTNERSHIP 402 2.DISTRIBUTOR ❑4.PROCESSOR ❑ 6.OTHER 403 E] 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.) 404 ❑Yes ® No 405 T"BT1 /"�c Lc /26 �7 L`� 406 II.PROPERTY OWNER INFORMATION PROPERTY O R NAME _ _ 407 PHONE C O tsV 408 t-,, T;,-� I., _ L.LC- (209)447-364-3 MAILING OR STREET ADDRESS n n - 409 7 I CITY 410 1 STATE 411 ZIP CODE 9S---It,.7 412 STOCKTON CAT PROPERTY OWNER TYPE 1 CORPORATION ❑ 2.INDIVIDUAL ❑ 4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY 1�LL C ❑3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY 413 III.TANK OWNER INFORMATION TANK OWNER NAME /� 1 ` qlq PHONE 5 415 tl `` 1 l`U U l f)Rs )% 209 444-M4-3- MAILING OR STREET ADDRESS /'� ,~` ^ ^-7 � y � 416 �/ v � Ll /L11� 2t)J rrir mxr TT c �� CITY 417 STATE 418 ZIP CODE 419 STOCKTON CA -95269- S S7,-IG.7 TANK OWNER TYPE ❑X 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- t ti,3,9 I Call(916)322-9669 if questions arise 421 V.PETROLEUM UST FINANCIAL RESPONSIBILITY INDICATE METHOD(s) ❑ 1.SELF-INSURED ❑4.SURETY BOND ,❑ 77 STATE FUND 1:110.LOCAL GOVT MECHANISM El 2.GUARANTEE El 5.LETTER OF CREDIT LJy 8.STATE FUND&CFO LETTER [9199.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 information provided herein is true and accurate to the best of my knowledge. SIGNAT RE F PL ANT DATFy,'///// % U� 424 P ONE C� ` G _ r,425 4� (� NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 427 mac. , '�k.c✓� 6 t-r-J STATE UST FACILITY NUMBER(For 1-1 ue only) 428 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 Is 1998 Compliant?Y UPCF(1/99 revised)