HomeMy WebLinkAbout7991 WHITE LANE_UST APP WHITE WATER AUTOUNDERGROUND STORAGE TANKS
UNIFIED PROGRAM CONSOLIDATED FORMS
0
APPLICATION
UST FACILITY (STATE FORMA)
TYPE OFACTION: (Check one item only) 1. NEWSITE PERMIT
2. INTERIM PERMIT
a E R S A 1 D
FIRM
ARTM T
BAKERSFIELD FIRE DEPARTMENT
Prevention Services
1501 Truxtun Avenue, 1sT Floor
Bakersfield, CA 93301
Phone: 661-326-3979 ® Fax: 661-852-2171
Page 1 of 2
3. RENEWAL PERMIT ® 5. CHANGE OF INFORMATION (Specify change- 7. PERMANENTLY CLOSED SITE
4. AMENDED PERMIT local use only) 6. TANKREMOVED 400
6. TEMPORARY SITE CLOSURE
I. FACILITY/SITE INFORMATION
13USINESS NAME (Same as FACILITY NAME or DBA - Doing Business As) 3 FACILITY ID No t
hitewater Auto Care
NEAREST CROSS STREET 4ot FACILITY OWNER TYPE
991 White Lane 1. CORPORATION 4. LOCAL AGENCY /DISTRICT`
White Lane & Gosford Rd
2. INDIVIDUAL 11 5. COUNTY AGENCY'
3. PARTNERSHIP 6. STATE AGENCY'
7. FEDERAL AGENCY' 402
BUSINESS TYPE 0 1. GAS STATION 3. FARM 5. COMMERCIAL
2. DISTRIBUTOR 4. PROCESSOR 6. OTHER
403
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 IM No 4o5 Name of supervisor of division, section or office
3 hick operates the UST. (This is the contact
person for the lank records.) (Please print Contact person's name) a
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
CITY 410 STATE 411 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 ,,, pHONE 41
Same As Above
AILING OR STREET ADDRESS 416
CITY 417 STATE 418 ZIP CODE 411
TANK OWNER TYPE ® 1. CORPORATION 2. INDIVIDUAL 4. LOCAL AGENCY/ DISTRICT 6. STATE AGENCY
3. PARTNERSHIP 5. COUNTY AGENCY 7. FEDERAL AGENCY 420
IV. OFaE9QUALIZATIONSUST STORAGE FEE
Y(TK)HO 4 4 o i
BBOARD
42
V. PETROLEUM UST FINANCIAL RESPONSIBILITY
x 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 B. 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 02. PROPERTY OWNER 3. TANK OWNER 42
VII. APPLICANT SIGNATURE
Certification: I certify that the information rovided herein is true and accurate to the best of m knowledge.
IGNA RE OF PLIC 1 2dAu o t aware 4T
By. crporationnoiEs
DATE a25 PHONE 42bpmaan{e
Sofa i ems r 407 265 -7348
AME OF APPLICANT (print) 427 TITLE OF APPLICANT 42
Christopher P. Tessitore j Executive Vice President
STATE UST FACILITY NUMBER (For local use only) 429 1998 UPGRADE CERTIFICATE NUMBER (For local use only) 43
FD 2093 (Rev. 10/08)