COMPLIANCE INFO_1995-2006 - Laserfiche WebLink

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• � IED PROGRAM CONSOLIDATED FO • 02 ` ��'f TANKS UNDERGROUND STORAGE TANKS - FACILITY 02 /U'L (one page per site) Pag of TYPE OF ACTION ❑ 1.NEW SITE PERMIT ❑3.RENEWAL PERMIT ❑5.CHANGE OF INFORMATION ❑ 7.PERMANENTLY CLOS (Check one item only) ❑4.AMENDED PERMIT specify change local use only ❑ 8.TANK REMOVED ❑6.TEMPORARY SITE CLOSURE 400 L FACILITY/SITE INFORMATION BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 FACILITY ID# USA GASOLINE#835 ADDRESS: 401 FACILITY OWNER TYPE ❑4.LOCAL GENCY/DISTRICT* 2705 COUNTRY CLUB BLVD., STOCKTON,CA 95204 ® 1.CORPO$ATION ❑5.COUNTY AGENCY* BUSINESS ®1.GAS STATION ❑3.FARM ❑5. COMMERCIAL ❑ 2.INDIVIDUAL ❑6.STATE AGENCY* TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR❑6. OTHER 403 ❑ 3.PARTNERSHIP ❑7.FEDERAL AGENCY* 402 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 REMAINING AT SITE trustlands7 operates the UST(This is the contact person for the tank records.) 3 404 ❑ Yes ® No 405 406 II. PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407 PHONE 409 PALISADES GAS AND WASH,INC. 818/865-9200 MAILING OR STREET ADDRESS 409 30101 AGOURA CT., SUITE 200 CITY 410 1 STATE 411 1 ZIP CODE 412 AGOURA HILLS CA 91301 PROPERTY OWNER TYPE O L CORPORATION ❑2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY [:13.PARTNERSHIP [15.COUNTY AGENCY ❑7.FEDERAL AGENCY 413 III. TANK OWNER INFORMATION TANK OWNER NAME 414 PHONE 415 PALISADES GAS AND WASH, INC. 818/865-9200 MAILING OR STREET ADDRESS 416 30101 AGOURA CT., SUITE 200 CITY 417 1 STATE 419 ZIP CODE 419 AGOURA HILLS CA 91301 TANK OWNER TYPE ® 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- 1 1 1 1 10 1 1 18 1 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 ❑2.GUARANTEE [:15.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 OWNER 423 VII. APPLICANT SIGNATURE Certification-I certify that the information provided her is true d accurate to the best of my knowledge. SIGNATURE OF APPLICANT DATE 424 1 PHONE 425 .j )j IL 818/865-9200 NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 427 JOHN J. ZISK OPERATIONS MANAGER STATE UST FACILITY NUMBER(For local use only) 428 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 UPCF(1/99 revised) Formerly SWRCB Form A