COMPLIANCE INFO_2001-2009 - Laserfiche WebLink

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�NIFIED PROGRAM CONSOLIDATED FOR PR #: PR0231692 FAC #: FA0000212 14 UNDERGROUND STORAGE TANKS - FACILITY TYPE OF ACTION ❑ 1. NEW SITE PERMIT ❑ 3. RENEWAL PERMIT ❑ 5. CHANGE OF INFORMATION ❑ 7. PERMANENTLY CLOSE=17711- (Check one item only)4. AMENDED PERMIT ❑ 8. TANK REMOVED ❑ 6. TEMPORARY SITE CLOSURE 03 JUL 23 PM 2: 39 I. FACILITY / SITE INFORMATION 444 W MOSSDALE RD, LATHROP BUSINESS NAME (same as FACar1Y NAME or DBA - Doing ��c Hess As) 3 FACILITY ID# PR ID# MBP MOSSDALE* FA0000212 PR0231692 TT� I1 NEAREST CROSS STREET FACILITY OWNER TYPE ❑ 4. LOCAL AGENCY/DISTRICT- 401 MOSSDALE 191. CORPORATION ❑ 5. COUNTY AGENCY- ❑ 2. INDIVIDUAL ❑ 6. STATE AGENCY- BUSINESS 1. GAS STATION ❑ 3. FARM ❑ 5. COMMERCIAL TYPE 2. DISTRIBUTOR ❑ 4. PROCESSOR E]6. OTHER 403 ❑3. PARTNERSHIP 402 [:]7. FEDERAL AGENCY* TOTAL NUMBER OF TANKS REMAINING AT SITE Is facility on Indian Reservation or trustlands? *Ifowner ofUST is a public agency: name ofsupervisor ofdivision, section or office which operates the UST (This is the contact person for the tank records.) 404 ❑ Yes ® No 405 NICK BOKIDES 406 Il. PROPERTY OWNER INFORMATION PROPERTY OWNER NAME / _ 407 't� v lll�,h 1s��- PHONE = 8 V Vc7��LS 11 MAILING OR STREET ADDRESS 409 `% _7L4 21�L�R CITY 410 1 STATE all ZIP CODE 412 �S �6 7 STOCKTON CA - 52m- 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 r-Y 414 Ps7 �' PHONE1 als MEL BOKIDES (2091 MAILING OR STREET ADDRESS /� `�' 416 CITY 417 STATE 411 1 ZIP CODE_ 419 - �'� -7 STOCKTON CA TANK OWNER TYPE 1�1 1, CORPORATION [12. 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- i-H s-a. 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 19199. 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� 1. FACILITY2. PROPERTY OWNER ❑ 3. TANK OWNER 423 S� Legal notifications and mailing will be sent to the tank owner unless box I or 2 is checked. VII. APPLICANT SIGNATURE Certification -1 certify that the infyrm on provided herein is true and accurate to the best ofmy knowledge. r- SIGNAT T DATE 424 PHONE 425 =F NAME OF APPLICANT (print) 426 TITLE OF APPLICANT 427 C} /-M, tic �.-y V/`\ STATE UST FACILITY NUMBER (For foal ue only) 428 1998 UPGRADE CERTIFICATE NUMBER (For local use only) 429 Is 1998 Compliant? Y UPCF (1/99 revised)