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UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> «„ 9MSMl <br /> TYPE OF ACTION C I.NEWSITEPERNrt Cl J.RENEWAL PERma SCHANGE OF WFORWTON fSpOry omm.- ❑ T.PERMANEMLY m mw SDE <br /> fct an.9.m.my1 1F aa.oNy1 ❑ B.TANK REMOVED 4Cq <br /> I.AMENOEO PERMIT <br /> Cl e.TEMPORARY SITE CLOSURE <br /> 1.FACILITY I SITE INFORMATION <br /> SUSWESS NAAIE(SAm.m FAGUTY NAME a OSA-Oavq BAM1.a A•1 l FACILITY ID 8 1 <br /> San Joaquin Mosquito & Vector Control District <br /> NEAREST CROSS STREET 401 FACUTY OWNER TYPE C 4 LOLL AGENCY/OISTNI <br /> Stimpson Street 0 '' MRPORATION i 1 ccur AGENCY` <br /> ❑i INOMOW C A. STATE AGENCY <br /> BUSINESS ❑ 1 GAS STATION C31.FARM 111 COMMERCU ❑ 1 PARTNERSHIP <br /> TYPE C T. FEDERALAGENCr 401 <br /> [32 pSTRIBUTOR 134.MOLESSOR A e.OTNER 40] <br /> TOTAL NUMBER OF TANKS (Tht u IMW UmSnTbAC P0A <br /> MNING AT SITE 'mm411F0M.11 bkiYM ruMmM.nalmftPUl.SllVTl. <br /> 2 Y. . <br /> a.b <br /> 109 <br /> ■NR 49s John Stroh <br /> II.PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME40T PHONE 4� <br /> San Joaquin County Mosquito & Vector Control District 800-300-4675 <br /> 09 <br /> ARMING OR STREET ADDRESS <br /> 7759 South Airport Way <br /> 010A 41t .12 <br /> Stockton CA 95206 <br /> PROPERTY OMERTYPE C 2 INOIVIWAL ❑ 4. LOCAIAGEN (DISTRICT C 9. sTATEAGENCY 418 <br /> ❑ 1. CCRAORATICN C3 5. PARTNERSHIP d S.couN AGENCY ❑ 1. FWERALAGENCY <br /> III.TANIL OWNER INFORMATION <br /> TANK OWNER NAME 414 ?HONE US <br /> San Joaquin County Mosquito & Vector Control District 800-300-4675 <br /> "UNGOR STREETADORESS 419 <br /> 7759 South Airport Way <br /> H STATE 418 ZP CODE 410 <br /> Stockton I CA 95206 <br /> TANK ONNERTYPE ❑ 2 INW ❑4. LOOALAGEN(.Y I DISTRICT C 1 STATEAGFNCY 420 <br /> C I' MWORAnoN Cl 1 PMTNERSHIP 5.COUNTY AGENCY C 7 -,cDERALAGENCY <br /> TV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 4 4 Call(916)322-9669 it questions arise u1 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDIGTE METHODIST C 1. SEWNSUREO C 4. SURETYBONO ❑ ). STATE FUND ■ ,0. LO GcvTMECIIAMw <br /> C Z GUARANTEE C s. LEnEROFCREDIT C 4 STATE MNO&CFOLETIER C W. OTHER: 4u <br /> C 1 INSURANCE C A. EJIEMPT1oN C 9. STATE FUND AM <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Clrmta.bmlm.ltioll vNtl1 A99lYA Al1oU19MUWbW+I ROMIFJW.�rRHY19. C 1. FACXM Z PROPOM OVMER C 0.TNM OWNER 420 <br /> LA9m 11.011oMM Alm mrlAq.M b1 arK m er wt.f.1f I14NA�1 a 1l.tMtlIK <br /> — VB.APPLICANT SIGNATURE <br /> C4rueAd[ IOM9 <br /> RE OF PATE 4N PHONE 4Z9 <br /> as owner agent 4/13/00 916-372-7535 <br /> N4MECFAY (gmf) 418 TRIS OF APPl1CAM 4TJ <br /> Barry E. Edmiston Administrative Assistant <br /> STATE LIST FACWtt NUMBER(Formolwarm) 418 I 1999UPGRADECE ncATENUMBERfhM ..w 419 <br /> UPCF(199) Faffmrly SWRCB Fa A <br />