Laserfiche WebLink
av <br /> UNIFIED PROGRAM CONSOLIDATED FORM �� ll <br /> rTII KS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page per site) <br /> Page _ a _ <br /> TYPE OF ACTION r 1.NEW SITE PERMIT r 3.RENEWAL PERMIT r 5.CHANGE OF INFORMATION icharge- r 7.PERMANENTLY CLOSED SITE <br /> (Check one dem only) r' 4.AMENDED PERMIT A�,pSe Onty) r6.TANKREMOVED 400 <br /> r 6.TEMPORARY SITE CLOSURE <br /> I.FACILITY I SITE INFORMATION <br /> BUSINESS NAME(Same as FACILITY NAME ar DBA-Dolrp Susloesa As) 3 FACILITY 10# <br /> Raymond Investment corporation F 00 NI$3 <br /> NEAREST CROSS STREET a01 FACILITY OWNER TYPE r 4. LOCAL AGENCYIDISTRICT• <br /> Channel atN. Grant St. Stockton DCI. CORPORATION r 5. COUNTYAGENCY' <br /> BUSINESS TYPE [' 1.GAS STATION r 3.FARM r 5.COMMERCIAL r L INDNIOUAL r 6. STATE AGENCY- <br /> r 2 DISTRIBUTOR r 4.PROCESSOR K 6,OTHER r 3. PARTNERSHIP r 7. FEDERAL AGENCY' 402 <br /> former SMART facility ao3 <br /> TOTAL NUMBER OF TANKS Is fadliry on IMian Reservation Of '#owner or UST u a oaolic agerk.Y:name of supemsor of <br /> REMAINING AT SITE trusllanGs'! nr (Tim,a.On.comity p snfa ales oetoUs6T <br /> 404 one rYes #ENO 405 406 <br /> 11.PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 406 <br /> Raymond Investment Corporation ' (209) 466-8604 <br /> MAILING OR STREET ADDRESS 409 <br /> P.O. Box 567 <br /> TATE 411 ZIP OD 412 <br /> CITY 410 <br /> Stockton <br /> CA 95201 <br /> PROPERTY OWNERTYPE r 2 INDIVIDUAL r C LOCAL AGENCY I DISTRICT r 6. STATEAGENCY 413 <br /> Ps 1. CORPORATION r 3. PARTNERSHIP r 5. COUNTY AGENCY r 7. FEDERALAGENCY <br /> III.TANK OWNER INFORMATION <br /> PHONE 415 <br /> TANK OWNER NAME 414 <br /> Ra mond investment Cor oration (209) 466-8604 <br /> MAILING OR STREET ADDRESS 416 <br /> P.O. Box 567 <br /> CI 417 STATE 416 IP OD 419 <br /> Stockton CA 195201 <br /> TANK OWNER TYPE r 2. INOMOUAL r 4. LOCAL AGENCY I DISTRICT r 6. STATEAGENCY 420 <br /> IK 1. CORPORATION r 1 PARTNERSHIP r S. COUNTYAGENCY r 7. FEDERALAGENCY <br /> TY(TK)HO 4 4 1 - I I I I Call(916)322-9669 if questions arise 421 <br /> INDICATE METHOO(S) r 1. SELF4NSURED r 4. SURETY BOND r 7. STATE FUND r 10. LOCAL GOV=T MECHANISM <br /> r 2. GUARANTEE r S. LETTER OF CREDIT r 6. STATE FUND d CFO LETTER r 99. OTHER:-422 <br /> r 3. INSURANCE r S. EXEMPTION r 9. STATE FUND&CD <br /> Check lro to mdicale whits iscol a shoots be u440 far legal nc@Imtbns arW mailep. r 1. FACILITY X 2. PROPERTY OWNER r 3. TANK OWNER 423 1 <br /> 1 M A 1112 t 1 N k b 1 2 Merheb <br /> CwVfinlion: I cMllfy"t Me atbn Pro, hefeln is Wa an0 ao oy to me bast of my knowbOge. <br /> SIGNATURE OF APP "ATtE 424 PHONE 425 <br /> Ocober 4 2002 209 466-8604 <br /> NAME OF APPLI (pn10 426 TITLE OF APPLICANT 427 <br /> BEVERLY N. GARCI President <br /> STATE UST FACILITY NUMBER(Forbcsluseonly) 426 /996 UPGRADE CERTIFICATE NUMBER(Fbr)Ocal use0ni 429 <br />