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HomeMy WebLinkAbout6801 COLONY STREET (4)UNDERGROUND STORAGE TANKS UNIFIED PROGRAM CONSOLIDATED FORMS APPLICATION UST FACILITY (STATE FORMA) TYPE OF ACTION: (Check one Rem only) 1. NEW SITE PERMIT INTERIM PERMIT BAKERSFIELD FIRE DEPARTMENT Prevention Services 2101 H Street Bakersfield, CA 93301 Phone: 661-326-3979 • Fax: 661-852-2171 Page 1 of 2 3. RENEWAL PERMIT 5. CHANGE OF INFORMATION (Specify chenge- 7. PERMANENTLY CLOSED SITE 4. AMENDED PERMIT localuaeonly) 8. TANK REMOVED 400 S. TEMPORARY SITE CLOSURE. I. FACILITY /SITE INFORMATION BUSINESS NAME (Same as FACILITY NAME or DBA - Doing Business As) 3 FACILITY ID No 1 CarMax Auto Superstore H11111HUM NEAREST CROSS STREET - 401 FACILITY OWNER TYPE 6801 Colon Street CORPORATION 4. LOCAL AGENCY /DISTRICT' Y 2. 5. COUNTY AGENCY' Bakersfield, CA 93307 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 lends? Yes ® No 405 Name ofsupervisorof dMsicn, section or office which operates the UST. (This is the contact arson forthe tank records.) (Please print Contact person's name) 4 II. PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 4a7 4a CarMax The Auto Superstore 804) 747 -0422 MAILING OR STREET ADDRESS 409 12800 Tuckahoe Creek Parkway CITY Richmond 410 VA 41 23238 4 PROPERTY OWNER TYPE M 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 414Sameasabove 41 MAILING OR STREET ADDRESS 416 CITY 417 1 STATE 418 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 EQUALIZATION Y (TK) HO 4 4 Call (916) 322 -9669 If questions arise 421 PETROLEUMV. C 1. SELF - INSURED 5. LETTER OF CREDIT 9. STATE FUND & 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 X 2. PROPERTY OWNER 3. TANK OWNER 42 VII. APPLICANT SIGNATURE Certification: 1 certify that the Information provided herein Is true and accurate to the beat of rn knowlefte. SIGNATURE OF APPLICANT 424 DATE 42 42 NAME OF APPLICANT (print) 427 TITLE OF APPLICANT 42 STATE UST FACILITY NUMBER (Forlocal use only) 429 1998 UPGRADE CERTIFICATE NUMBER (Forlocal use only) 43 FD 2093 (Rev. 10108) UNDERGROUND STORAGE TANK PERMIT APPLICATION TO OPERATE AN UST 3r; +r PERMIT # TYPE OF APPLICATION (CHECK) b OPERATE NEW FACILITY TRANSFER OF OWNERSHIP BAKERSFIELD FIRE DEPARTMENT Prevention Services 2101 H Street Bakersfield, CA 93301 Phone: 661 - 326 -3979 . Fax: 661-852-2171 OPERATE AN EXISTING FACILITY PREVIOUS TANK OWNER (if applicable) ..._._-_ -- - - -- -- - -- -- NAME None PHONE # ADDRESS ICITY 1ZIP CODE NEW TANK OWNER NAME CarMax The Auto Superstore HONE fl ADDRESS 12800 Tuckahoe Creek Parkway CITY Richmond IP CODE 23238 BILLING ADDRESS Same CITY ZIP CODE TANK'OPERATOR if different from owner NAME CarMax The Auto Superstore PHONE # DDRESS 6801 Colony Street Il Y Bakersfield IP CODE 93307 APPLICANT'S NAME (if different from owner) NAME Same as owner PHONE # DDRESS ITl' IP CODE TANK LOCATION FACILITY NAME CarMax Auto Supertstore PPERATOR NAME PHONE # DDRESS 6801 Colony Street ITY Bakersfield IP CODE 93307 EMERGENCY CONTACT NAME Ed KellY HONE # 804) 747 -0422 ADDRESS 12800 Tuckahoe Creek Parkway ITY Richmond IP CODE 23238 TANK INFORMATION TANK # VOLUME DATE INSTALLED SUBSTANCE STORED PREVIOUS SUBSTANCE 1 12,000 gal pending unleaded gasoline none Do you have a HAZARDOUS MATERIAL RESPONSE PLAN? YES NO Do you have an OWNER - OPERATOR AGREEMENT? YES NO Have you filled out a HAZARDOUS MATERIAL BUSINESS PLAN? YES NO FOR OFFICIAL USE ONLY The applicant has received, understands, and will comply with the attached conditions of the permit and any other state, local and federal regulations. This form has been completed under penalty of perjury, and to the best of my knowledge, is true and correct. APPLICANT SIGNATURE APPLICANT NAME (PRINT) APPROVED BY THIS APPLICATION BECOMES A PERMIT WHEN APPROVED S: Forms - Web \Fire \UST\FD2087 UST Permit Application to Operate an UST.doc (Rev 06/10)