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)