COMPLIANCE INFO_1986-2005 - Laserfiche WebLink

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UNIFIED PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS - FACILITY (one page per site) Page_of TYPE OF ACTION ❑ 1.NEW SITE PERMIT ❑3.RENEWAL PERMIT 105.CHANGE OF INFORMATION ❑ 7TERMANENTLY CLOSED SITE (Check one item only) ❑4.AMENDED PERMIT specify change local use only(fI"A)C 8.TANK REMOVED ❑&TEMPORARY SITE CLOSURE 400 I. FACILITY/SITE INFORMATION BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 FACILITY ID# ----T71 %i% oo i iU FAI 1 AREST CROSS STREET 401 FACILITY OWNER TYPE El 4.LOCAL AGENCY/DISTRICT* A)671.CORPORATION ❑5.COUNTY AGENCY* BUSINESS Lj 1.GAS STATION Ll 3.FARM 5. COMMERCIAL 2.INDIVIDUAL ❑6.STATE AGENCY* TYPE [12.DISTRIBUTOR [14.PROCESSOR X6. 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 SITEtrustlands? operates the UST(This is the contact person for the tank records.) Oat ❑ Yes N No aos 406 II. PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407 PHONE 408 MAILING OR STREET ADDRESS 409 o Oat v /[nI S O - [T; 410 STATE 411 ZIP CODE 412 S6;-0112 /\) -5 � J D. .;,) I PROPERTY OWNER TYPE N 1.CORPORATION 2.INDIVIDUAL Lj 4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY 413 III.TANK OWNER INFORMATION TANK OWNER NAME 414 PHONE 415 -'�--J veraz 3 MAILING OR STREET ADDRESS 416 t� T' 2 o cq_/ © /-'- CITY - 417 1 STATE j418 1 ZIPCO0 7,5F-2- 419 TANK OWNER TYPE 1.CORPO TION 2.INDIVIDUAL L1 4.LOCAL AGENCY/DISTRICT Ll 6.STATE AGENCY 420 [13.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY TK HQ 44- 1 Q 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 9 2.GUARANTEE ❑5.LETTER OF CREDIT ❑8.STATE FUND&CFO LETTER ❑ 99.OTHER: ❑3.INSURANCE [16.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 I or 2 is checked. ❑ 1.FACILITY ❑2. PROPERTY OWNER ❑3.TANK OWNER 423 VII.APPLICANT SIGNATURE Certification-1 certify that the information provided herein is true and accurate to the best of my knowledge. SIGNATU FAPP ANT DATE p� �7 ata PHONE 425 NA OF APPLICT(print) r 426 TITLE OF APPL CANT 427 LC I ( r�G STATE UST FACILITY NUMBER(For local use only) 428 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 UPCF(1/99 revised) 8 Formerly SWRCB Form A