COMPLIANCE INFO_2003-2012 - Laserfiche WebLink

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I1NIFTED PROGRAM(',ONSOIJDATF,D FORM KJ\ TANKS lA11 pk5 UNDERGROUND STORAGE TANKS - FACILIT (one page per site) Page a of TYPE OF ACTION ❑ 1.NEW SITE PERMIT ❑3.RENEWAL PERMIT ❑5.CHANGE OF INFORMATION ❑ 7.PERMANENTLY CLOSED SITE (Check one item only) IN 4.AMENDED PERMIT specify change local use only ❑ 8.TANK REMOVED ❑61EMPORARY SITE CLOSURE 400 I. FACILITY/SITE INFORMATION BUSINESS NAME(Same as FACILrrY NAME or DBA-Doing Business As) 3 FACILITY ID# S.M.K.CHEVRON _5P 5_ � I I I FTI I I I I1 NEAREST CROSS STREET 401 FACILITY OWNER TYPE ❑4.LOCAL AGENCY/DISTRICT• 25651 N 99 W FRONTAGE RD HWY 99,ACAMPO,95220 ❑ 1.CORPORATION ❑5.COUNTY AGENCY* BUSINESS ER 1.GAS STATION El 3.FARM 5. COMMERCIAL IN 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 ttustlands? operates the UST(This is the contact person for the tank records.) 3 4w ❑ Yes ® No 405 406 U. PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407 PHONE 408 VICTOR STRAIN TRUST none MAILING OR STREET ADDRESS 409 P.O.BOX 325 CITY 410 1 STATE 411 ZIP CODE 412 OAKVILLE CA 94562 PROPERTY OWNER TYPE El 1.CORPORATION 2.INDIVIDUAL 0 4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY TRUST ❑3.PARTNERSHIP [15.COUNTY AGENCY ❑7.FEDERAL AGENCY 413 III.TANK OWNER INFORMATION TANK OWNER NAME 414 PHONE 415 HARVINDER PAL SINGH 209-333-0305 MAILING OR STREET ADDRESS 416 1224 VIENNA DRIVE CITY 417 1 STATE 418 ZIP CODE 419 LODI CA 95242 TANK OWNER TYPE El 1.CORPORATION 2.INDIVIDUAL Ll 4.LOCAL AGENCY/DISTRICT El 6.STATE AGENCY 420 [13.PARTNERSHIP ❑5.COUNTY AGENCY [17.FEDERAL AGENCY IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY TK HQ 44- 1 1 1 1 1 1 Call 916 322-9669 if questions arise 421 V.PETROLEUM UST FINANCIAL RESPONSIBILITY INDICATE METHOD(s) ❑1.SELF-INSURED ❑4.SURETY BOND IN 7.STATE FUND [110.LOCAL GOVT MECHANISM ❑2.GUARANTEE [15.LETTER OF CREDIT ❑8.STATE FUND&CFO LETTER ❑ 99.OTHER: ®3.INSURANCE [16.EXEMPTION ❑9.STATE FUND&CD 422 VL 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. ❑ L FACILITY [12. PROPERTY OWNER EN 3.TANK OWNER 423 VII.APPLICANT SIGNATURE Certification-I certip that the information provided herein is true and accurate to the best of my knowledge. SIGNATU OF APPLICANT^ DATE 1 424 PHONE 425 1-�-- l! J ! 7�n 209-333-0305 NAME OF PP ICANT(print) 426 TITLE OF APPLICANT 427 HARVINDER PAL SINGH OWNER STATE UST FACILITY NUMBER(For loeat use ody) 428 1998 UPGRADE CERTIFICATE NUMBER(For 1oca1 aw only) 429 UPCF(1/99 revised) 8 Formerly SWRCB Form A