HomeMy WebLinkAbout4600 STINE ROAD (2)CITY OF BAKERSFIELD
d~~/~ - OFFICE OF ENVIRONMENTAL SERVICES
~R i~ 1715 Chester Ave., Bakersfield, CA 93301 (661) 326-3979 '~~
_. ~~ .~...-
UNDERGROUND STORAGE TANKS - UST FACiLITY
Page _ of _
TYPE OF ACTION ~~, NEW SITE PERMR ^ J. RENEWAL PERMIT ^ S. CHANGE OF INFORMATION (SpedN ~~ange - ^ 7. PERMANENTLY CLOSED SITE
(CAeck one ifem on/y)
^ 0. AMENDED PERMIT bca/ use onty) ^ 8. TANK REMOVED ypp,
^ 8. TEMPORARY SITE CLOSURE
I. FACILITY / SITE INFORMATION
BUSINESS NAME (Same ae FACILITY NAME a 08A • Ooing Busineat A~) 3 FACIL(TY ID +f ~
NEAREST CROSS STREET ~ 407. fACILITY OWNER TYPE
^ 4. LOCAL AGENCYlDISTRICT'
O v~I 1. CORPORATION
^ 5. COUMY AGENCY'
INDNIDUAL
BUSINESS
FARM ^ 5
COMMERCIAI
GAS STATION ^ 3
^ 1 .
^ 8. STATE AGENCY'
.
.
.
T,PE
^ 2. DISTRIBUTOR ^ 4. PROCESSOR ^ 8. OTHER a03. 3. PARTNERSHIP
^ 7. FEDERAL AGENCY• qpZ_
TOTAL NUMBER OF TANKS Is fadliry on Indian Reservati~on a 'If owner of UST a puDlic agenq: name of wpervisor of
REMAINING AT SITE 7Wtlands9 divisian, sepion or dflte whith operates t~e UST.
(Thiu is Uie oontatt pCrsOn fa Ne tar+k records.)
4W. ^ Yes No 405. ~.
. II. PROPERTY OWNER INFORMATION .
PROPERTY WNER NAAAE
~
~ 407.
~ PHONE 408,
L~ ~~Q.W`
~ VO~ QY ~l` ~ ~
409.
Rf,
.~~.
MAILING O STREET
~
~
~
{
~7y t~ 410.
~ ~
l~~ STATE 41 t. LP CADE 412.
~
ccs ? 330~
PROPERTY OWNER TYPE ^ y, p,~pMWAL ^ 4. LOCAL AGENCV / DISTRICT ^ B. STATE AGENCY 413.
^ 1. CORPORATION pqRTMERSHIP ^ S. COUNTY AGENCY ^ 7. FEDERAL AGENCY
111. TANK'OWNER INFORMATION .
TANK 0 ER NAME 414. Ph10NE 415.
~~3~ ~`a
~ o
~~ 416.
RESS
MAILING R ST AD
~
~
C~7y 417. STATE 418. ZIP CODE 419.
~
TANK OWNER ^ 2. INDMDUAL ^ 4. IOCALAGENCYlDISTRICT ^ 8. STATEAGENCY 420.
^ t. CORPORATION pqRTMERSHIP ^ 5. COUMfI'AGENCY ^ 7. FEDERALAGENCY
N. BOARD OF EQUALIZATION U8T 8TORAGE FEE ACCOUNT NUMBER
TY (TK) Hf] 4 4 - Call (916) 322-9669 if questlons a~ise a2~.
,, ; :...:..... ... . ..
, _,. ,.,...: . ... . . ,
,.' :; : V. PETROLEUM UST FINANCIAL RESPONSIBILiTY .
INDICATE METHOO(S) ~. ~~.~NSURED ^ 4. SURET`f BOND ^ ~. STATE FUND ^ 10. LOCAL GOVT MECHANISM
^ 2. GUARANTEE ^ 5. LETfER OF CREDIT , ^ 8. STATE FUND 8 CFO LETTER ^ 99. OTHER:
^ 3. INSURANCE ^ B. FJ(EMPTION 9. STATE FUND 8 CO 4~'
VL LEGAL NOTIFICATION AND MAILING ADDRESS
Chedc ane box to inNcate which adN~ ~hould De uaetl fd legal notiflcatbns and mtiling. ^~
FACILITY
PROPERTY OWNER ^ 3
TANK OWNER 423. '
,
.
.
legal nodfleaUons and mailings will De ~ent ro lhe tank owna unless Dox t ar 2 is chedced.
VII. APPUCANT SIGNATURE ~
CartitlpGan: I oerti a e'ntamaUan prwiCed herdn is We and aaunte to the bast af my knavledge.
SIGNATURE OF ICANT DATE 424. PHONE 425.
7-5 v t~6( Zl 3~Z o
428.
NAME 0 LICANT nt) _ TITLE OF APPLICA
427.
r! ~~
w h
UPCF (7/99) S:\CUPAFORMS~swrcb-a.wpd
, State uf California For State Use Only
Stat~ uf Water Resources Control Boarcl
. . Division uf Financial Assistance
P.O. Bur 944212
Sacramentu, CA 9424~1-212Q
(Instructions on reverse side)
CERTIFICATION OF FINANCIAL RESPONSIBILITY
FOR UNDERGROUND STORAGE TANKS CONTAINING PETROLEUM
A. I am required to demonstrate Financial Responsibility in the Required amounts as specified in Section 2807, Chapter 18, Div. 3, Tide 23, CCR:
^ 500,000 dollars per occurrence ~ ~ million dollars annual aggregate
or AND or
~ I million dollars
er occurrence ~ 2
illi
d
ll
l
p
m
on
o
azs annua
aggregate
B. hereby certifies that it is in compliance with the requirements of Section 2807,
(Neme ol Tank Owner a OperatoQ
Article 3, Chapter 18, Division 3, Tit/e 23, Califomia Code of Regulations.
The mechanisms used to demonstrate financial responsibility as required by Sec6on 2807 are as follows:
C. Mechanism Mechanism Coverage Coverage Corredive Third Party
T e Name and Address of Issuer Number Amount Period Adion Com
SeIF Pc~t~cc.. ~ous~" ( ~M,~~to~( lo t~-~ . H~JE- ~~"
~~~V~Ci. ~ Q ~~ ~c~, ~o (
S~ . nno
Note: If you aie using the State Fund as any part of your demonstration of financial responsibility, your execution and submission of
this ceRification also ceRifies that you are in compliance with all c~onditions for participation in the Fund.
D. Facility Name Faality Address
g~~ ~< <<~ 4
Facility Name Facility Address
Facility Name Facility Address
E. Signat a k Owner or Operator Date Name and Title ot Tank Owner or Operator
- ~--- 7- s~o~. o,..~
' natu of itne or Notary Date Name of Witness or Notary
~rK ~eceviseo ~arn~ FILE: Origlnal - Local Agency ' Copie~ - Facllity/Site(e)