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04/17!2007 09:24 916-373-1172 ' --A1 ��IIJaI <br /> WALTON ENGINEEP-JG / <br /> UNIFIED PROGRAM CONSOLIDATED FORA, I i4l 1 01- <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACII "!/1ele7 <br /> (One page per site) Page_or_ <br /> TYPE OF ACTION ❑I.NEW PERMIT ❑7,RENEWAL PERMIT ❑5.CHANGE OF INFORMATION 1, <br /> (Check one item only) LI 4.AMENDED PERMIT (Specifyebaage) ®8.TANK REMOVED LYCLO$ED SITE 490. <br /> / S Q El 6.TEMPORARY SITE CLOSURE <br /> BUSINESS NAME(roep,FAen,AnMe �-0oll,eae.meukACT�yIW9111�t`'i 'TI&TY <br /> ., <br /> Joe's Travel Plaza IDs <br /> NEAREST CROSS STREET nol. FACILITY OWNBR TYPE fU7. <br /> OCAL AGENCYRSISTRICT* 4*2 <br /> Thomsen Rd. ❑1.CORPORATION OUNTY AGENCY- <br /> AR <br /> BUSINESS 1.GAS STATION 3.FARM 5,COMMERCIAL 402, ®2,INOTVIDUAL TATE AGENCY" <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR ❑6.OTT4ER ❑.3,PARTNERSUTP BDFRAL AGENCY* <br /> TOTAL NUMBER OF TANKS 4M Is facility on Indian Reservation nos. 4 f owner of UST is a public agency: name o 511pavisot of division,semen or Ona. <br /> REMAINING AT SITE m tnuel lands? efBce which opwant the UST. (This is the cnnMM person for the(nnk mord..) <br /> 3 ❑Ycs ®No <br /> PROPER r?OWNER NAME, 407 PHONE <br /> nos. <br /> DalwinderDhoot 209-275-2708 <br /> MAILING OR STREET ADDRESS 4m <br /> 15600 S.Harlan Rd. <br /> ITV 414 STATE 411 1 ZIP CODE 412 <br /> Lathrop CA 95330 <br /> PROPERTY OWNER TYPE ❑ 1.CORPORATION M 2,INDIVID(IAL 4,LOCAL AGENCY f DISTRICT Ll 6.STATE AGENCY 413. <br /> ❑3.PARTNFRSNIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> JIM,TAt It:'O"r�VP�t') MAT16N. <br /> TANK OWNER NAME nw. PHONE nis. <br /> Dalwinder Dhoot 2o9-z7s•27os <br /> MAILING OR STREET ADDRESS 415. <br /> 15600 S. Harlan Rd. <br /> CITY 4n. STATE 41x, ZIPCODE <br /> 419, <br /> Lathrop CA 95330 <br /> TANK OWNER TYPE ❑ I.CORPORATION N 2,INDIVIDUAL Q 4,LOCAL AGENCY/DfSTRICT E16.STATEA0SNCY 426. <br /> ❑3.PARTNERSHIP ❑$,COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> I�. $OA1R or EQUALIZATION UST STORAGE j Ac6ot 1WT NtmoER <br /> TY TK 14Q 44- Call 916)322-9669 if uestions arise 421. <br /> 81. PET�OLEVM,UST FINANCIAL tttu SII q YTV <br /> INDICATE METHOD(s) O 2_ GUARMD EONI7 NTEF [2 5.LETTER OF CREDIT El 8,STATE FUND k CFO LET <br /> ❑Io.LOCAL GOVT MECHANISM 4U <br /> TER 1199.OTHBR; <br /> ❑;,INSURANCE ❑6.EXEMPTION [19 STATE FUND k CD <br /> 9I, LE(;AL NOTIFICATION AND MAILING ADDRESS <br /> Cheek one boa to milleate which address should be used For Iepal nmlRealIel',and mailing. <br /> Lepel nnHRenllons and moil lop will he sent he On wk owner unless hoe 1 e,2-e d,celred. ❑ 1,FACILITY 0 2. PROPERTY OWNER ❑3.TANK OWNER 421. <br /> 1711. APPUCANNT,46A- <br /> Ccnifclevion: I comfy Ihnt the fMmannn PMvidml Inman is tjoc.nd n alms to the beel nF my knowledge. <br /> SIGNATURE PPL( T DATE 424 PHONE 425 <br /> 4/16/07 916.373-1152 <br /> NAME OFAPPLICANT(pri t) 4n TITLE OF APPLICANT 427, <br /> Michael E.Walton Contractor <br /> STATE UST FACILITY NUMBER(Agency asaooly) 429. 1998 UPGRADE CERTIFICATE NUMBER(Aaenn we only) nes. <br /> (See Dnta Element I,above. <br /> UPCF 14wRvre•R(1199)-1/2 http://wmm.unidneA.org Rev,02/16/00 <br />