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03/04/2002 11:34 2094673"6 AGE STOCKTON ����Cko. �eAGE 02/02 <br /> 4 IED PROGRAM COKS OLEDATED FO' r O 0 <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> 4tJ:Co/V ?L717 (oRe page pe s e) Page_nt'_ <br /> TYPE OF ACTION ❑1.NEW PERry T [13 RENEWAL PERMIT HANCE OFINFORMATION ❑7.PERMANENTLY CLOSED SI'1 1 4- O <br /> (Chcd one item only) ❑4.AMENDED PERMIT (Sped 'd+nnge) �R.TANKREMOVED <br /> ❑6.TEMPORARY SITE CLC=F, \ <br /> s ss <br /> ON <br /> EDSIVESS NAMEfs<,,:. :9 a!ngos EOE-poor e�mm a.v)<•< 3:.::'f4CL.n� . <br /> vEqRET T FACILITY OWNER TYPE ❑4.LOCAL AGENCY/DISTRICT' 4e, <br /> UTlN <br /> ❑ L CORPORATION ❑5.COUNTY AGENCY* <br /> BUSINESS ❑ 1.GAS STATION ❑3.FARM 5.COMMERCIAL, °a3. XINDIVIDUAL ❑6.STATE AGENCY- <br /> TYPE ❑2.DISTRIBUTOR ❑4,PROCESSOR ❑6.OTHER ❑3.PARTNERSHIP ❑7.FEDERAL AGENCY' <br /> TOTAL.NUMBER OF TANKS 4W. Is facility on Indian Resmtimtian au, 'If owner or U37 is a public agencyrare of supervisor of division,eedim or 466 <br /> REMAINING AT SJ7E D or trust tends? oftiae whic!t operaes the US'f. (11vs u the nonta t person fi+.tho tank reomds.) <br /> 2e� r Yas <br /> YC. PkOPERTV Oti�N R AMFORliATTON _ Y <br /> _.. <br /> dc2- <br /> PIioPL:RTtCnt� F.IjNAMP� ° YHONE <br /> IXAMAILING OR STREET ADDRESS 409. <br /> D 2 2( <br /> CITYI'! ll V/4 01i STATE 411. ZIPCODE 412: <br /> PROPERTY OWNER TYPE 4A 1.CORPORATION ),j 2.INDIVIDUAL U 4.LOCAL AGENCY/DISTRICT ❑6,STATE•AGENCY 413. <br /> ❑3.PARTNERSHIP ❑S_COUNTY AGENCY [:17.FEDERAL AGENCY <br /> TANS WNERNE 4!a. FkIO*1E - 415.... <br /> f'�, <br /> L <br /> MAILING OR STREET ADDRESS 416. <br /> 8 <br /> clTt srATE .le. ZIPCODE 419 <br /> 1 Ua l <br /> TANKO i ER TYPE ❑ 1.CORPORATION _INDIVIDUAL El4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 426. <br /> ❑3.PARTNERSHIP 5.COCEN'CY AGENCY __❑7.FEDERAL.AGENCY <br /> It-. BOARD OF EQUALIZATION UST StORAGC TFC A(f COT DST-T-IRTP, <br /> TY TK HQ 4d- <br /> call ii l ! lcl arise <br /> V. PETROLEUM UST FINANCML RESPOh51BiLITA <br /> ..< _ <x: <br /> INDICATE METHOD(s) ❑ I.SELF INSLRED ❑�s SURETYSOND ❑7.ST .zL ❑10 LOCAL OOV r :H., 9.i .� <br /> ❑2.GUARANTEE El <br /> OF CRE017 ❑R.S1\ '.O R 7FC LFTTL-R ❑99.OTHER <br /> ❑3.INSURANCE ©6.ExTT'lPTION ❑9.STATE FLTD S <br /> k+` 6.PlL'3+Tq'. #CATION AlY)Ylf ( ING ADAn'SS <br /> (had.one lam to rrahunewhich 1dra,. ahold trc mal(ar!agnl nisi fisatmna and rr i e :.< - • <br /> Legal notiliesamu end mailings will be suit to die lank owner unless boslrn^_ie u:as! ] LPACILITY ydz. �-ROPPRTY OWNER °.'IAvK O�D^SEP, <br /> VIL APPLlcdhx SICNATirIttS <br /> «, _ <br /> Cati6rorim !cuti(y tba tha info d' pmvi4cd h mm u true aid Recinaa!o rhe bast ofnq brow c <br /> SIGNATURE DATE 4V <br /> PHONE 4zC 5/ ^ i 47 d <br /> NAME OF AP (print 4 . TITLEFPLICANT 427 <br /> . <br /> I , l <br /> Rs <br /> STATE UST FACILITY NUMBER(Am,,uss only) '"°a. 1993 UIKRADE CERTIFICATE NU ER C8596aco*i 4xa <br /> (See Deter Element 1,above, <br /> UPCF Elvrfwre-a(1/99)-1/2 http://www.unidne.,.org Hec.02/16/00 <br />