COMPLIANCE INFO_1989-2010 - Laserfiche WebLink

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�NIFIED PROGRAM CONSOLIDATED FORJO PR a: PR0234251 F FA0003508 1)01 UNDERGROUND STORAGE TANKS - FACILI (one page per site) TYPE OF ACTION ❑ I. NEW SITE PERMIT �3. RENEWAL PERMIT ❑ 5. CHANGE OF INFORMATION ❑ 7. PERMANENTLY CLOSED SITE CC (Check one item only) ❑ 4. AMENDED PERMIT INS Mello 8. TANK REMOVED ❑ 6. TEMPORARY SITE CLOSURE 400 I. FACILITY / SITE INFORMATION 2771 E FRENCH CAMP RD, MANTECA BUSINESS NAME (Same as FACILITY NAME or DBA - Doing Business As) 3 FACILITY ID# PR ID# ACE TOMATO CO INC FA0003508 PR0234251 NEAREST CROSS STREET FACILITY OWNER TYPE ❑ 4. LOCAL AGENCY/DISTRICT• FRENCH CAMP 401 ❑ 1. CORPORATION ❑ 5. COUNTY AGENCY* [_1 2. INDIVIDUAL 6. STATE AGENCY- ❑ BUSINESS ❑ 1. GAS STATION ❑ 3. FARM ❑ 5. COMMERCIAL TYPE 2. DISTRIBUTOR 4. PROCESSOR ❑ 6. OTHER 403 E] 2. ❑ 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 operates REMAINING AT SITE trustlands? the UST (This is the contact person for the tank records.) 404 El Yes ❑X No aosACE TOMATO CO INC 406 II. PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407 PHONE aos ACE TOMATO CO INC 209 478-7142 MAILING OR STREET ADDRESS 409 2771 E FRENCH CAMP RD CITY 411 STATE 411 ZIP CODE 412 MANTECA CA 1 95336 PROPERTY OWNER TYPE ❑ 1. CORPORATION ❑ 2. INDIVIDUAL ❑ 4. LOCAL AGENCY / DISTRICT ❑ 6. STATE AGENCY ❑ 3. PARTNERSHIP ❑ 5. COUNTY AGENCY ❑ 7. FEDERAL AGENCY 413 III. TANK OWNER INFORMATION TANK OWNER NAME 4141 PHONE 415 ACE TOMATO CO INC 209 478-7142 MAILING OR STREET ADDRESS 416 2771 E FRENCH CAMP RD CITY 411 STATE 418 ZIP CODE 419 MANTECA CA 1 95336 TANK OWNER TYPE ❑ 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- 44-025075 1 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 ❑ 2. GUARANTEE 1:15. LETTER OF CREDIT ❑ 8. STATE FUND & CFO LETTER ❑X 99. OTHER ❑ 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. ® 1, FACILITY ❑ 2. PROPERTY OWNER ❑ 3. TANK OWNER 423 Legal notifications and mailing will be sent to the tank owner unless box I or 2 is checked. VII. APPLICANT SIGNATURE Certification -1 certify that the information provided herein is true and accurate to the best of my knowledge. SIGNATURE OF APPLICANT DATE 424 PHONE 425 NAME OF APPLICANT (print) 426 TITLE OF APPLICANT 427 STATE UST FACILITY NUMBER (For local ue only) 428 1998 UPGRADE CERTIFICATE NUMBER (For local use only) 429 1 Is 1998 Compliant? Y UPCF (1/99 revised)