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IFIED PROGRAM CONSOLIDATED FOG" erv__'� <br /> ) TANKS <br /> UNDERGROUNDSTORAGE TANKS - FACILITY (til <br /> (one page per site) Page-of <br /> TYPE OF ACTION ❑ 1.NEW SITE PERMIT ®3.RENEWAL PERMIT ❑5.CHANGE OF INFORMATION ❑ 7.PERMANENTLY CLOSED SITE <br /> (Check one item only) ❑4.AMENDED PERMIT specify change local use only ❑ 8.TANK REMOVED <br /> ❑6.TEMPORARY SITE CLOSURE 400 <br /> 1: <br /> FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 FACILITY ID# <br /> IF �Aj I ul <br /> Valero Corner Store#3641 1 <br /> NEAREST CROSS STREET 401 FACILITY OWNER TYPE 4.LOCAL GENCY/DISTRICT* <br /> Kathleen Drive ® 1.CORPORATION [15.COUNTY AGENCY* <br /> BUSINESS ® 1.GAS STATION ❑3.FARM 0 5. COMMERCIAL ❑ 2.INDIVIDUAL ❑6.STATE AGENCY* <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR❑6. OTHER 403 ❑ 3.PARTNERSHIP ❑7.FEDERAL AGENCY* 402 <br /> 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 <br /> REMAINING AT SITE trustlands? which operates the UST(This is the contact person for the tank records.) <br /> 3 404 ❑ Yes ® No 405 406 <br /> II,'P,R®PERTY,OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408 <br /> Shadrall Associates 1 201-930-8800 <br /> MAILING OR STREET ADDRESS 409 <br /> 50 Tice Blvd. c/o Auburndale Pori erties <br /> CITY 410 STATE 411 1 ZIP CODE 412 <br /> Woodcliff Lake I NJ 07675 <br /> PROPERTY OWNER TYPE 1.CORPORATION El 2.INDIVIDUAL Lj 4.LOCAL AGENCY/DISTRICT [:16.STATE AGENCY <br /> ®3.PARTNERSHIP ❑5.COUNTY AGENCY [:17.FEDERAL 413 <br /> IiL TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> Valero California Retail Company 559-582-0241 <br /> MAILING OR STREET ADDRESS a1s <br /> 685 W 3rd Street <br /> CITY 417 STATE 416 ZIP CODE 419 <br /> Hanford CA 93230-5000 <br /> TANK OWNER TYPE 1.CORPORATION [12.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT 6.STATE AGENCY 420 <br /> ❑3.PARTNERSHIP [15.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION,UST STORAGE FEE ACCOUNT NUMBER <br /> TY TK HO 44- 2 4 6 6 0 Call 916 322-9669 if questions arise 421 <br /> V.PETROLEUM UST FINANCIAL RIESPONSOOTY <br /> INDICATE ® 1.SELF-INSURED ❑4.SURETY BOND [:17.STATE FUND ❑ 10.LOCAL GOVT MECHANISM <br /> METHOD(s) [:12.GUARANTEE [15.LETTER OF CREDIT ❑B.STATE FUND&CFO LETTER ❑ 99.OTHER: <br /> ❑3.INSURANCE ❑6.EXEMPTION ❑9.STATE FUND&CD 422 <br /> VL 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.FACILITY [12. PROPERTY OWNER ®3.TANK 423 <br /> OWNER <br /> VIS.APPLICANT SIGNATURE <br /> Certification-I certify that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNATURE OF APP LI T DATE 424 PHONE a25 <br /> osllf 559-583-3298 <br /> NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 427 <br /> Sandy Huff Operations & Environmental Specialist <br /> STATE UST FACILITY NUMBER(For local use only) 428 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 <br /> UPCF(1/99 revised) Formerly SWRCB Form A <br />