HomeMy WebLinkAbout1701 STINE ROADUNDERGROUND STORAGE TANKS
UNIFIED PROGRAM CONSOLIDATED FORMS
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APPLICATION
UST FACILITY (STATE FORMA)
TYPE OF ACTION: (Check one item only) 1. NEW SITE PERMIT
2. INTERIM PERMIT
B E R S F I '' D
FIRE '>
AR TM T
BAKERSFIELD FIRE DEPARTMENT
Prevention Services
1501 Truxtun Avenue, 1ST Floor
Bakersfield, CA 93301
Phone: 661 - 326 -3979 a Fax: 661 - 852 -2171
Page 1 of 2
3. RENEWAL PERMIT ® 5. CHANGE OF INFORMATION (Specify change- 7. PERMANENTLY CLOSED SITE
C AMENDED PERMIT local use only) e. TANK REMOVED 400
6. TEMPORARY SITE CLOSURE
I. FACILITY /SITE INFORMATION
BUSINESS NAME (Same as FACILITY NAME or DBA - Doing Business As) 3 FACILITY ID No 1
hitewater Auto Care
NEAREST CROSS STREET 401 FACILITY OWNER TYPE
1701 Stine Road 1. CORPORATION 4. LOCAL AGENCY /DISTRICT'
Stine Road &Ardmore Avenue
2. INDIVIDUAL 5. COUNTY AGENCY'
3. PARTNERSHIP 6. STATE AGENCY'
7. FEDERAL AGENCY' 402
BUSINESS TYPE ® 1. GAS STATION 3. FARM 5. COMMERCIAL
2. DISTRIBUTOR 04. PROCESSOR 6. OTHER
40
TOTAL NUMBER OF TANKS Is facility on Indian Reservation or If owner of UST a public agency: Give the
REMAINING AT SITE 404 Trust lands? Yes ® No 405 Name of supervisor of division, section or office
1 which operates the UST. (This is the contact
arson for the tank records.) (Please print Contact person's name) 4
II. PROPERTY OWNER INFORMATION
PROPERTY OWNER NAME
i
407 PHONE 40
NNN CA Auto Svc LLC, a Delaware limited liability company
By: NNN Development, Inc., a Maryland corporation, its Sole Member 407)265 -7348
AILING OR STREET ADDRESS 409
50 S. Orange Ave. Suite 900
CITY 410 STATE Ott ZIP CODE 41
Orlando FL 2801
PROPERTY OWNER TYPE ® 1. CORPORATION 2. INDIVIDUAL 4. LOCAL AGENCY/ DISTRICT 6. STATE AGENCY
3 . PARTNERSHIP 5. COUNTY AGENCY O 7. FEDERAL AGENCY 413
III. TANK OWNER INFORMATION
TANK OWNER NAME 414 PHONE 41
Same As Above
AILING OR STREET ADDRESS 416
CITY 417 STATE 41e ZIP CODE 41
TANK OWNER TYPE ® 1. CORPORATION 2. INDIVIDUAL 4. LOCAL AGENCY/ DISTRICT 6. STATE AGENCY
3, PARTNERSHIP 5. COUNTY AGENCY 7. FEDERAL AGENCY 420
IV. BOARD OF EQUALIZATION UST STORAGE FEE
TY (TK) HO 4 4 0 2 9 E Call (916) 322 -9669 if questions arise 421
V. PETROLEUM UST FINANCIAL RESPONSIBILITY
1. SELF - INSURED 5. LETTER OF CREDIT 9. STATE FUND 8 CD
INDICATE METHOD(S) 2. GUARANTEE 6. EXEMPTION 10. LOCAL GOVT MECHANISM
3. INSURANCE ® 7. STATE FUND 99. OTHER:
4. SURETY BOND 8. STATE FUND & CFO LETTER
4
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 1 or 2 is checked. 1. FACILITY O2. PROPERTY OWNER 3. TANK OWNER 42
VII. APPLICANT SIGNATURE
Certification: I certify that the information provided herein Is true and accurate to the best of my knowledge.
SIGNATU5,E OF APPLICANT 1 Y t bd aware 424 DATE 425 PHONE 42
yMar landvc Or Oration, its SoleRembe 407 265 -7348
NAME OF APPLICANT (print) 427 TITLE OF APPLICANT 42
I
Christopher P. Tessitore I Executive Vice President
STATE UST FACILITY NUMBER (For local use only) -- 429 1998 UPGRADE CERTIFICATE NUMBER (For local use only) 43
FD 2093 (Rev. 10108)