COMPLIANCE INFO_1995-2006 - Laserfiche WebLink

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FIED PROGRAM CONSOLIDATED FO ti TANKS UNDERGROUND STORAGE TANKS - FACILITY (one page per site) Page_of TYPE OF ACTION ❑ 1.NEW SITE PERMIT ❑3.RENEWAL PERMIT ❑5.CHANGE OF INFORMATION ❑ TPERMANENTLY CLOSED SITE (Check one item only) ®4.AMENDED PERMIT specify change local use only ❑ 8.TANK REMOVED ❑&TEMPORARY SITE CLOSURE 400 I. FACILITY f SITE INFORMATION ' BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) g FACILITY,ID# NELLA Oil Company #427 NEAREST CROSS STREET 401 FACILITY OWNER TYPE ❑4. LOCAL GENCY/DISTRICT' Report Ave ❑ 1.CORPORATION [:15. COUNTY AGENCY` BUSINESS ® 1.GAS STATION Q 3.FARM Q 5. COMMERCIAL ❑ 2, INDIVIDUAL ❑6.STATE AGENCY` TYPE ❑2. DISTRIBUTOR Q 4.PROCESSOR❑ 6. OTHER 403 ® 3.PARTNERSHIP ❑7. FEDERAL AGENCY* 4o2 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 REMAINING AT SITE trustlands? which operates the UST(This is the contact person for the tank records.) 3 404 ❑ Yes ❑ No 405 406 II: PROPERTY OWNER,INEORMATION PROPERTY OWNER NAME 407 PHONE 408 Quentin Kirsch 713 744 4152 MAILING OR STREET ADDRESS 409 190 Amber Way CITY 410 STATE 411 ZIP CODE 412 Hanford CA 93230 PROPERTY OWNER TYPE ❑ 1. CORPORATION ® 2. INDIVIDUAL ❑4. LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY ❑ 3. PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL 413 III.TANK'O NER FORMATION TANK OWNER NAME 414 PHONE 415 NELLA Oil Company 530 885-0401 MAILING OR STREET ADDRESS 416 2349 Rlckenbacker Way CITY STATE 418 ZIP CODE 419 Auburn CA 95602 TANK OWNER TYPE ❑ 1. CORPORATION ❑ 2. INDIVIDUAL ❑4. LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 42o ® 3. PARTNERSHIP ❑5.COUNTY AGENCY ❑ 7. FEDERAL AGENCY IV. BOARD OFZQUALIZATION UST'STO GE FEE ACCOUNT NUMBER TY (TK) HO 44- 0 1 9 18 19 Call (916) 322-9669 if questions arise 421 V PETROLEUM UST FINANCIAL RESPONSIBILITY; INDICATE ❑ 1. SELF-INSURED ❑4.SURETY BOND ❑7.STATE FUND ❑ 10. LOCAL GOVT MECHANISM METHOD(s) ❑2. GUARANTEE ❑5. LETTER OF CREDIT ®8.STATE FUND&CFO LETTER ❑ 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. Legal notifications and mailings will be sent to the tank owner unless box 1 or 2 is checked. ❑ 1.FACILITY ®2. PROPERTY OWNER ❑3.TANK 423 OWNER vn. APPLICANT'S RE Certification-I certify that the inform n provided herein is true and accurate to the best of my knowledge. SIGNATURE OF L I N DATE 424 PHONE 425 j J?(DI530-885-0401 NAME OF APPI ANorint) 425 TITLE OF APPLICANT 427 Jack "c a fi !director of Encineerina vMBEP r_a_se only) 1998 UPGRADE CERTIFICATE NUMBER For iocai use onlO 429 r .