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TFIED PROGRAM CONSOLIDATED FORM PR#:PR0231330 <br /> FAC#:FA0003964 <br /> UNDERGROUND STORAGE TANKS -FACILI 3 <br /> V 13 <br /> 4 (one page per site) <br /> TYPE OF ACTION ❑ 1.NEW SITE PERMOr ❑3.RENEWAL PERMIT 5.CHANGE OF INFORMATION <br /> (Check use item only) ❑ ❑ 7.PERMANENTLY CLOSED SITE <br /> ❑4.AMENDED PERMIT ❑8.TANK REMOVED <br /> 116.TEMPORARY SITE CLOSURE 400 <br /> I.FACILITY/SITE INFORMATION 230 W ELM ST.LODI <br /> BUSINESS NAME(Smeae FACILITY NAMm or DBA-Dong nmhacs M) 3 FACILITY ID# PR ID# <br /> LODI PUBLIC SAFETY BUILDING FA0003964 PR0231330 <br /> NEAREST CROSS STREET FACILITY OWNER TYPE <br /> ELM 61 ❑ I.CORPORATION ❑4.LOCAL AGENCY/DISTRICT' <br /> BUSINESS El S.COUNTY AGENCY' <br /> 1 <br /> ,TYPE ❑ .GAS STATION E] 3.FARM ❑ 5.COMMERCIAL ❑ 2.INDIVIDUAL ❑6.STATE AGENCY' <br /> ❑ 2.DISTRIBUTOR ® 4.PROCESSOR ❑6.OTHER 463 ❑ 3.PARTNERSHIP ❑ 7.FEDERAL AGENCY" 402 <br /> TOTAL <br /> A NUMBS4ING AT OF TANKS F�"tcjamds,faility on Indian Reservation or gfownm of UST is a public agency:name ofsupervisor ofdivision,section moBice which operates <br /> REMthe UST(This is the contact person for the lank records.) <br /> Yes ®No 105 LODI CITY OF/DENNIS CALLA '06 <br /> I1.PROPERTY OWNER INFORMATION <br /> PROPERTY OWNERNAME 407 PHONE ba <br /> LODI CITY OF 209 334-5634 <br /> MAILING OR STREET ADDRESS 4a9 <br /> 221 W PINE <br /> CITY 410 STATE 011 ZIP CODE 412 <br /> LODI CA 95240 <br /> PROPERTY OWNER TYPE ❑ 1.CORPORATION ❑ 2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY <br /> ❑3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY 413 <br /> II.TANK OWNER INFORMATION <br /> TANKOWNERNAME414 PHONE as <br /> LODI CITY OF 209 334-5634 <br /> MAILING OR STREET ADDRESS <br /> 416 <br /> 221 W PINE <br /> CITY 417 1 STATE418 ZIP CODE 419 <br /> LODI CA 95240 <br /> TANK OWNER TYPE ❑ 1.CORPORATION ❑ 2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY 420 <br /> ❑ 3.PARTNERSHIP 1:15.COUNTY AGENCY ❑ 7.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 44-024650 1 Call(916)322-9669 if questions arise 431 <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ❑ 1.SELF-INSURED ❑4.SURETY BOND ❑ 7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM <br /> ❑2.GUARANTEE ❑S.LETTER OF CREDIT ❑ 8.STATE FUND.$CFO LETTER W 99.OTHER <br /> ❑3.INSURANCE ❑6.EXEMPTION ❑ 9.STATE FUND&CD 4u <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one box to indicate which address should be used for legal notifications and mailing. ® 1,FACILITY ❑2.PROPERTY OWNER ❑3.TANK OWNER 4D <br /> Legal notifications and mailing will be sent to the task owner unless box 1 or 2 is checked. <br /> VIL APPLICANT SIGNATURE <br /> Certification-I certify dud the infomution provided herein is we and accurate to the best ofmy knowledge. <br /> SIGNATURE OF APPLICANT DATE 424 1 PHONE 423 <br /> NAME OF APPLICANT(print) 436 TITLE OF APPLICANT 422 <br /> STATE UST FACILITY NUMBER(For lwvl tie only) 428 1998 UPGRADE CERTIFICATE NUMBER(Fwlootmeony) 429 <br /> Is 1998 Compliant?Y <br /> UPCF(1/99 revised) <br />