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Home My WebLink About920 34TH STREETUNDERGROUND STORAGE TANKS UNIFIED PROGRAM CONSOLIDATED FORMS a E R S P t D aC m rAt r APPLICATION UST FACILITY (STATE FORMA) M TYPE OF ACTION: (Check one item only) t. NEW SITE PERMIT 2. INTERIM PERMIT BAKERSFIELD FIRE DEPARTMENT Prevention Services 1501 Truxtun Avenue, 15T 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. PERMANENTLYCLOSED SITE 4. AMENDED PERMIT local use only) 8. 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 t 4th Street Restaurant & Car Wash CROSS STREET 4ot FACILITY OWNER TYPE 920 34 Street203Street CORPORATION 4. LOCAL AGENCY /DISTRICT' 4th Street & O Street 2. INDIVIDUAL [1 5. COUNTY AGENCY` 3. PARTNERSHIP 6. STATE AGENCY' 7. FEDERAL AGENCY' 402 BUSINESS TYPE ® 1. GAS STATION 3. FARM 5. COMMERCIAL 2. DISTRIBUTOR 4. 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 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 CITY 410 STATE Ott 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 414 PHONE 41 Same As Above AILING OR STREET ADDRESS 418 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 Y (TK) HO 4 4 10 8 1 Call (916) 322 -9669 if questions arise 42t V. PETROLEUM UST FINANCIAL RESPONSIBILITY O 1. SELF - INSURED 5. LETTER OF CREDIT 9. STATE FUND & CO INDICATE METHOD(S) 2. GUARANTEE 6. EXEMPTION 10. LOCAL GOVT MECHANISM 3 INSURANCE © 7. STATE FUND 99. OTHER: 4. SURETY BOND 8. STATE FUND 8 CFO LETTER a 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 ® 2. 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. SIGNATURE OF APPLICANT A o Delaware 424 ATE 425 PHONE a i Aed yitLLC6ma corr-oiaPonInc SoleLeLgan 407 265 -7348 NAME OF APPLICANT (print) 427 TITLE OF APPLICANT 42 Christopher P. Tessitore Executive Vice President TATE UST FACILITY NUMBER (For local use only) 429 1998 UPGRADE CERTIFICATE NUMBER (Forlocal use only) 43 FD 2093 (Rev. 10/08)