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NIFIED PROGRAM CONSOLIDATED FORM PR a:PR0506221 FAC 0:FA0007287 UNDERGROUND STORAGE TANKS - FACILITIC�/ �J 612�`�(-Chq (2vF- �(on/e page perSlt�� C��I�� TYPE OF ACTION ❑ 1.NEW SITE PERMIT ❑ 3.RENEWAL PERMIT S.CHANGE OF I N FORMATION ❑ 7.PERMANENTLY CLOSED SITE (Check one item only) ❑ 4.AMENDED PERMIT specify6m elocal.e My 3 ❑ 8.TANK REMOVED ❑ 6.1'ESIPORARY SITE CLOSCRE 40i I.FACILITY/SITE INFORMATION 14931 N FLAG CITY BLVD,LODI BUSINESS NAME(s.mea FACaIT(SAME,ueA-Dauyjg.i.as A.) 3 FACILITY 11 PR IDH FLAG CITY ARCO/SUBWAY FA0007287 P.. ".21 NEAREST CROSS STREET FACILITY OWNER TYPE ❑4.LOCAL AGENCY/DISTRICT- FLAG CITY 401 ® I.CORPORATION ❑ 5.COUNTY AGENCY- BUS[NE ❑2.INDIVIDUAL 1.GAS STATION ❑ 3.FARM ❑ i COMMERCIAL ❑6.STATE AGENCY' TYPE 2.DISTRIBUTOR ❑4.PROCESSOR ❑6.OTHER 403 ❑3.PARTNERSHIP ❑ 7.FEDERAL AGENCY• TOTAL NUMBEROF TANKS Is facility on Indian Reservation or •Ifewner of UST is a public agency:name ofsuperrisorofdwision,senioo or office which operates REMAINING AT SITE tzdands? the OST(This is the contact person for the tank records) I 404 ❑ Yes M No 405 406 1I.PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407 PHONE HALLOUM YOUSIF 1 MAILING OR STREET , / a r �p /yams_j., jo/ w9 / J " CITY 410 STATE 411 ZIP CODE 411 PROPERTY OWNER TYPE N1 1.CORPORATION ❑ 2.INDIVIDUAL ❑ 4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY 03.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY 413 III.TANK OWNER INFORMATION TANK OWNER NAME 414 PHONE 415 HALLOW YOUSIF Wi 1 MAILING OR STET ADDRESS / Q_S 416 CITY y 417 STATE 418 ZIPCODE 419 1 yla Ah.rL'rYA 3 CA 94S" TANK OWNER TYPE ❑x L CORPORATION ❑2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY 470 ❑ 3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY(TK)HQ 44- 44-037709 1 Call(916)322-9669 if questions arise 431 V.PETROLEUM UST FINANCIAL RESPONSIBILITY INDICATE METHOD(s) ❑ 1.SELF-INSURED 114.SURETY BOND ❑ 7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM ❑2.GUARANTEE ❑5.LETTER OF CREDIT I 8.STATE FUND&CFO LETTER SIT 99.OTHER [:13.INSURANCE ❑6.EXEMPTION 9.STATE FUND&CD 422 VI.LEGAL NOTIFICATION AND MAILING ADDRESS Check one box to indicate which address should be used for legal notifications and mailing. ® 1.FACILITY ❑2.PROPERTY OWNER ❑3.TANK OWNER 423 Legal notifications and mailing will be to the tank owner unless box 1 in_is checked. VII.APPLICANT SIGNATURE Certification-1 rtify th ravided herein is true and accurate to the best ofmy knowledge. SIGNATU OF APP DATE 424 PHONE 475 22 VV// a NAME OF CA ( nt) Q6 TITLE OF APPLICANT 427 STATE UST FACILITY NUMBER(Farlo.l aec*) 428 1998 UPGRADE CERTIFICATE NUMBER(For 1-1..only) 429 Is 1998 Compliant'.Y UPCF(1/99 revised)