COMPLIANCE INFO_2005-2010 - Laserfiche WebLink

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IFIED PROGRAM CONSOLIDATED Fr` ^A TAIyKS UNDERGROUND STORAGE TANKS - FACILITY 2�IZ/o��(�,�1I* (one page per site) Page of TYPE OF ACTION ❑ 1.NEW SITE PERMIT ®3.RENEWAL PERMIT ❑5.CHANGE OF INFORMATION ❑ 7.PERMANENTLY CLOSED SITE (Check one item only) ❑4.AMENDED PERMIT specify change local use only ❑ 8.TANK REMOVED ❑&TEMPORARY SITE CLOSURE 400 1. FACILITY/SITE INFORMATION BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 1 FACILITY Ifs# Valero Corner Store#3641 jFjAj7C)j () j() j 7 1 NEAREST CROSS STREET 401 FACILITY OWNER TYPE ❑4. LOCAL GENCY/DISTRICT` Kathleen Drive E 1.CORPORATION ❑5.COUNTY AGENCY' BUSINESS E 1.GAS STATION ❑3.FARM ❑5. COMMERCIAL ❑ 2. INDIVIDUAL [16.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 REMAINING AT SITE trustlands? which operates the UST(This is the contact person for the tank records.) 3 404 ❑ Yes E No 405 406 If. PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407 PHONE 408 Shadrall Associates 201-930-8800 MAILING OR STREET ADDRESS 409 50 Tice Blvd. c/o Auburndale Pori erties CITY 410 STATE 411 ZIP CODE 412 Woodcliff Lake NJ 07675 PROPERTY OWNER TYPE ❑ 1.CORPORATION ❑2. INDIVIDUAL ❑4. LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY E 3. PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL 413 III.TANK OWNER INFORMATION TANK OWNER NAME 414 PHONE 415 Valero California Retail Company 559-582-0241 MAILING OR STREET ADDRESS 416 685 W 3rd Street CITY 417 STATE 418 ZIP CODE 419 Hanford CA 93230-5000 TANK OWNER TYPE E 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 2 14 16 16 10 1 Call 916 322-9669 if questions arise 421 V. PETROLEUM;UST FINANCIAL RESPONSIBILITY INDICATE E 1.SELF-INSURED ❑4.SURETY BOND ❑7.STATE FUND ❑ 10. LOCAL GOVT MECHANISM METHOD(s) ❑2.GUARANTEE ❑5. LETTER OF CREDIT [18.STATE FUND&CFO LETTER ❑ 99.OTHER: ❑3. INSURANCE ❑6. EXEMPTION [19.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 [:12. PROPERTY OWNER ®3.TANK 423 OWNER VII. APPLICANT SIGNATURE Certification-I certify that the information provided herein is true and accurate to the best of my knowledge. SIGNATURE OF APPLI T DATE 424PHONE 425 ki i"Ix 4_�noS�l f�()1 559-583-3298 NAME OF APPLICANT(print) LJ 426 TITLE OF APPLICANT 427 Sandy Huff Operations & Environmental Specialist 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