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1 VIED PROGRAM CONSOLIDATED FORM �� 4,). PR :PR0523176 <br /> r.+s/ � y-Iii-O�,{I)n FACM AO01 <br /> UNDERGROUND STORAGE TANKS - FACILITY IIIb IVdO/ PL <br /> (one page Per site) /03 <br /> TYPE OF ACTION ❑ 1.NEW SITE PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENTLY CLOSED SITE <br /> (Check one iters,only) ❑4.AMENDED PERMIT speveyctunge load.,c* El 8.TANK REMOVED <br /> ❑6.TEMPORARY SITE CLOSURE 401 <br /> I.FACILITY/SITE INFORMATION 121 S CHEROKEE LN,LODI <br /> BUSINESS NAME(Smess FAMITYRAMlim DEA-Dom 13anucse As) I FACILITY IDN I PR IDN <br /> PANSKI PROPERTY FA0015W PR0523176 <br /> NEAREST CROSS STREET FACILITY OWNER TYPE <br /> wl ® I.CORPORATION ❑4.LOCALY AGENCY- <br /> BUSINESS <br /> BUSINESS ❑ 1 GAS STATION 2INDIVIDUAL ❑ S.COUNTY AGENCY• <br /> TYPB ❑ 3.FARM ❑ 5.OTHER UNI. ❑ ❑ 6.STATE AGENCY* <br /> ❑2.DISTRIBUTOR ❑4.PROCESSOR ❑ 6.OTHER 403 [13.PARTNERSHIP ❑ 7.FEDERAL AGENCY' 40Z <br /> TOTAL NUMBER OF TANKS Is facility on Indian Reservation or •H owns ed UST is a public egmry:rmne of supervisor oCdivision,section or office which operates <br /> REMAINING AT SITE trvstlands? the UST(This is the correct person for the tank records.) <br /> 404 ❑ Yes ® No 403 PANSKY,EMIL 406 <br /> H.PROPERTY OWNER INFORMATION <br /> PROPERTY OWNERNAME 401 PHONE <br /> PANSKY EMIL <br /> MAILING OR STREET ADDRESS <br /> 901 JACKLING DR 44%1 <br /> CTT STATE <br /> 410 411 ZrP CODE nz <br /> HILSBOROUGH CA 1 94010 <br /> PROPERTY OWNER TYPE ❑ I.CORPORATION ❑ 2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY <br /> ❑3.PARTNERSHM ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY 413 <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> PANSKY EMIL <br /> MAILING OR STREET ADDRESS <br /> 901 JACKLING DR 416 <br /> CITY STATE <br /> 417 418 ZIP CODE 419 <br /> HILSBOROUGH CA 94010 <br /> TANK OWNER TYPE ❑ 1.CORPORATION ❑2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 420 <br /> ❑ 3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 1 Call(916)322-9669 if questions arise a1 <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ❑ 1.SELF-rNSURED ❑4.SURETY BOND ❑ 7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM <br /> ❑2.GUARANTEE 1:15.LETTER OF CREDIT ❑ S.STATE FUND&CFO LETTER ®99.OTHER <br /> ❑3.INSURANCE ❑6.EXEMPTION ❑ 9.STATE FUND&CD 422 <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one box to ondicete which address should be used£or legal in ificatims and mailing, ❑ 1.FACILITY ®2.PROPERTY OWNER ❑3.TANK OWNER av <br /> Legal notifications and remains will be sets,ce Ne tank owner unless box 1 or 2 is checked. <br /> VIL APPLICANT SIGNATURE <br /> Ciatifiomen,-1 cerofy that the infotmatim provided herein is true and accurate to the best ofery knowledge. <br /> SIGNATURE OF APPLICAM DATE 424 PHONE 425 <br /> NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 427 <br /> STATE UST FACILITY NUMBER(For mw re mb) 428 1998 UPGRADE CERTIFICATE NUMBER(For mini.se dy) 429 <br /> Is 1998 Compliant? <br /> UPCF(1/99 revised) / <br />