COMPLIANCE INFO_1999-2008 - Laserfiche WebLink

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0IF ED F kOGRAM CONSOLIDATED FO PR#:PR0232418 1% FAC#:FA0004064 UNDERGROUND STORAGE TANKS -FACILITY 3 one page per site) 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 MEMINNNEIRIMEM ❑ 8.TANK REMOVED / ❑6.TEMPORARY SITE CLOSURE 400 I.FACILITY/SITE INFORMATION 2512 E WATERLOO RD,STOCKTON BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) g FACILITY ID# PR ID# 1 WATERLOO LIQUOR FA0004064 PR0232418 NEAREST CROSS STREET FAC OWNER TYPE aot ❑ 4.LOCAL AGENCY/DISTRICT- WATERLOO,-`M- I.CORPORATION ❑ 5.COUNTY AGENCY- BUSINESS ff 1.GAS STATION ❑ 3.FARM ❑ 5.COMMERCIAL ❑ 2.INDIVIDUAL ❑ 6.STATE AGENCY* TYPE ❑ [_1 3.PARTNERSHIP [:1402 2.DISTRIBUTOR ❑ 4.PROCESSOR ❑ 6.OTHIsR 403 7.FEDERAL AGENCY' TOTAL NUMBER OF TANKS Is facility on Indian Reservation or *Ifowner of UST is a public agency:name of supervisor of division,se on or .ce A�whihates REMAINING AT SITE trustlands? the UST(This is the contact person for-the tank-)---- ✓ , _ _ Ce 404 ❑ Yes ®No 405 ELUSO,ANTONIO f° 406 II.PROPERTY O R INFORMATIO PROPERTY OWNER NAME 407 P aos eI - MAILING OR STREET ADDRESS - � 409 1636 FILBERT CITY 410 STATE 411 ZIP CODE 412 STOCKTON CA 95205 PROPERTY OWNER TYPE 1.CORPORATION ❑ 2.INDIVIDUAL ❑ 4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY a ❑3.PARTNERSHIP ❑ 5.COUNTY AGENCY ( 7.FEDERAL AGENCY 413 II . OWNER INFORMAT TANK OWNER NAME I 414 PHONE ........ . --�� als Vu�I,l�rloo ,ti �n L 209 463-4114 MAILING OR STREET ADDRESS 416 - vZ S1 Z CITY 417 TATE 418 ZIP CODE 419 STOCKTON CA 5205,,' TANK OWNER TYPE V1.CORPORATION [:12.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- 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 AL GOVT MECHANISM ❑2.GUARANTEE 1:15.LETTER OF CREDIT ❑ 8.STATE FUND&CFO LETTER X 99.OT ❑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. M 1.FACILITY ❑2.PROPERTY OWNER ❑3.TANK OWNER 423 Legal notifications and mailing will be sent to the tank owner unless box 1 or 2 is checked. VII.APPLICANT SIGNATURE Certification-I certify that the information pro ' ed, rein is true d accurate to the best of my knowledge. SIGNATURE OF APPLICANT DATE 424 PHONE 425 NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 427 r M p STATE UST FACILITY R(For local ue only) 428 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 Is 1998 Compliant?Y UPCF(1/99 revised) TX