Laserfiche WebLink
WA <br /> UNOD PROGRAM CONSOLIDATED FORAW <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (One page per site) Page_of <br /> TYPE OF ACTION ❑1.NEW PERMIT ❑3.RENEWAL PERMIT ❑5.CHANGE OF INFORMATION ❑7.PERMANENTLY CLOSED SITE 400. <br /> (Check one item only) ®4.AMENDED PERMIT (Specify change)Equipment Modification ❑8.TANK REMOVED <br /> ❑6.TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3. FACILITY <br /> Fremont Shell M FM3 <br /> NEAREST CROSS STREET 401. FACILITY OWNER TYPE ❑4.LOCAL AGENCY/DISTRICT* 402. <br /> N. Filbert St. [11.CORPORATION ❑5.COUNTY AGENCY* <br /> BUSINESS N 1.GAS STATION [:13.FARM ❑5.COMMERCIAL 403. ®2.INDIVIDUAL ❑6.STATE AGENCY* <br /> TYPE [:12.DISTRIBUTOR [14.PROCESSOR ❑6.OTHER ❑3.PARTNERSHIP ❑7.FEDERAL AGENCY* <br /> TOTAL NUMBER OF TANKS 404. Is facility on Indian Reservation 405. *If owner of UST is a public agency: name of supervisor of division,section or 406 <br /> REMAINING AT SITE or trust lands? office which operates the UST. (This is the contact person for the tank records.) <br /> ❑Yes ®No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 408 <br /> Michael Dominguez 209-941-8743 <br /> MAILING OR STREET ADDRESS 409. <br /> 2494 E. Fremont Street <br /> CITY 410. 1 STATE 411. ZIP CODE 412 <br /> Stockton CA 95205 <br /> PROPERTY OWNER TYPE F11.CORPORATION ®2.INDIVIDUAL [:14.LOCAL AGENCY/DISTRICT 0 6.STATE AGENCY 413. <br /> ❑3.PARTNERSHIP [:15.COUNTY AGEN( Y ❑7.FEDERAL AGENCY <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> Michael Dominguez 209-941-8743 <br /> ` MAILING OR STREET ADDRESS 416. <br /> -� 2494 E.Fremont Street <br /> CITY 417. 1 STATE 418. ZIP CODE 419, <br /> Stockton CA 95205 <br /> TANK OWNER TYPE ❑ 1.CORPORATION ®2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 420 <br /> [:13.PARTNERSHIP ❑5.COUNTY AGENCY [-17.FEDERAL AGENCY <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY (TK)HQ 44- 1 1 1 Call(916)322-9669 if questions arise 421. <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ❑1.SELF-INSURED ❑4.SURETY BOND ®7.STATE FUND ❑10.LOCAL GOVT MECHANISM 422 <br /> ❑2.GUARANTEE ❑5.LETTER OF CREDIT ❑8.STATE FUND&CFO LETTER ❑99.OTHER: <br /> ❑3.INSURANCE ❑6.EXEMPTION ❑9.STATE FUND&CD <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS' <br /> Check one box to indicate which address should be used for legal notifications and mailing. <br /> Legal notifications and mailings will be sent to the tank owner unless box 1 or 2 is checked. [1 1.FACILITY [:12. PROPERTY OWNER ®3.TANK OWNER a23. <br /> VII.APPLICANT SIGNATURE <br /> Certification: I certify that t information provided herein is true and accurate to the best of my knowledge. <br /> SIGNATUR O AP AN DATE 424. 1 PHONE 425. <br /> 4/18/05 916-373-1152 <br /> NAME OF APPLICANT(print) 426. TITLE OF APPLICANT 427. <br /> Michael Walton Contractor <br /> STATE UST FACILITY NUMBER(Agency use only) 428. 1998 UPGRADE CERTIFICATE NUMBER(Agency use only) 429 <br /> (See Data Element 1,above. <br /> UPCF Hwfwrc-a(1/99)-1/2 http://www.unidoes.org Rev.02/16/00 <br />