HomeMy WebLinkAbout5201 STOCKDALE HIGHWAYIry
UNDERGROUND STORAGE TANKS
UNIFIED PROGRAM CONSOLIDATED FORMS
APPLICATION
UST FACILITY (STATE FORMA)
TYPE OF ACTION: (Check one item only) 1. NEWSITE PERMIT
2. INTERIM PERMIT
B B R S F t D
FIRE
ARM r
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 CLOSEDSITE
4. AMENDED PERMIT local use only) a. TANK REMOVED 400
8. 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
5201 Stockdale Highway 1. CORPORATION 4. LOCAL AGENCY /DISTRICT'
Stockdale Highway &California Ave /New Stine Road9Y
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
3 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 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
ITY 410 STATE at1 ZIP CODE 41
Orlando FL 32801
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 4t4 PHONE at
Same As Above
AILING OR STREET ADDRESS 418
CITY 417 STATE ate ZIP CODE 41
TANK OWNER TYPE IR 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
Y (TK) HO q 4 Q Q Call (916) 322 -9669 if questions arise 421
V. PETROLEUM UST FINANCIAL RESPONSIBILITY
1, SELF - INSURED 5. LETTER OF CREDIT 9. STATE FUND & CD
INDICATE METHOD(S) 2. GUARANTEE 6. EXEMPTION 10. LOCAL GOVT MECHANISM
3. INSURANCE (Z1 7. STATE FUND 99. OTHER:
4 SURETY BOND O 8. STATE FUND & CFO LETTER
42
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 0 2. PROPERTY OWNER 3. TANK OWNER a
VII. APPLICANT SIGNATURE
Certification: I certify that the information rov'do harein is true and accurate to the best of my knowledge.
SIGNATURE OF APPLICANT 1 @ O YyC lZCaD waY 4z4 ATE 425 PHONE 42
1 t cb p y
aLb
ionn, I Soleyand
e e 407 265 -7348
NAME OF A LICANT (print) 427 TITLE OF APPLICANT 42
Christopher P. Tessitore 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)