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UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page per sire) <br /> - _--- Papa _ of _ <br /> TYPE OF ACTION XI' 1.NEW SITE PERMIT r 3.RENEWAL PERMIT r 5.CHANGE OF INFORMATION(Specify change- r 7.PERMANENTLY CLOSED SITE <br /> (Check one item ouy) <br /> 4 AMENDED PERMIT local use only) r B.TANK REMOVED 400 <br /> r <br /> F 6 TEMPORARY SITE CLOSURE <br /> 1.FACILITY I SITE INFORMATION ) oZ 14 <br /> BUSINESS NAME(Sema as FACILITY NAME or OBA-Dung Business As) 3 FACILITY Io Y <br /> Joe Omachi Property <br /> NN ESTET 1 <br /> FACILITYOMERTYPE r 4. LOCALAGENCY/DISTRICT' <br /> rrp 1. CORPORATION r 5. COUNTY AGENCY` <br /> BUSINESS TYPE r 1.GAS STATION r 3.FARM r 5.COMMERCIAL qs2. INDIVIDUAL r 6. STATE AGENCY' <br /> r 2.DISTRIBUTOR r 4.PROCESSOR Xr 6.OTHER r 3. PARTNERSHIP r 7. FEDERAL AGENCY' 402 <br /> 403 <br /> TOTAL NUMBER OF TANKS is facility on Indian Reservation or of owner of UST is a public agency name&supervisor of <br /> REMAINING AT SITE lrustlands7 division,section.r.Rice which Weretas the UST. <br /> I00 1 g <br /> (This is the contact person for the tank records.) <br /> r Yes is No 405 AM <br /> II.PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408 <br /> Joe Omachi 2 8070 <br /> - <br /> IT65 RElE Monte CITY 4os <br /> 410 $TATE 411 IP C DE 412 <br /> Stockton, CA 95207 <br /> PROPERTY OWNER TYPE 1X2. INDIVIDUAL r 4. LOCAL AGENCY/DISTRICT r 6. STATE AGENCY 413 <br /> r 1. CORPORATION r 3. PARTNERSHIP r 5. COUNTY AGENCY L7. FEDERALAGENCY <br /> III.TANK OWNER INFORMATION <br /> TANKOWNERNAME 414 PHONE 415 <br /> Same as above <br /> MAILING OR STREET ADDRESS 416 <br /> 417 STATE 418 ZIP 419 <br /> TANK OWNER TYPE r 2. INDIVIDUAL r 4. LOCAL AGENCY/DISTRICT r 6. STATE AGENCY 420 <br /> r t. CORPORATION r 3. PARTNERSHIP r S COUNTY AGENCY r 7. FEDERALAGENCY <br /> TY(TK)HO 4 4 1 Call(916)322-9669 if questions arise 421 <br /> INDICATE METHODS) FX SELF-INSURED r 4. SURETY BOND r 7. STATE FUND r 10. LOCAL GOV=T MECHANISM <br /> F 2. GUARANTEE r 5. LETTER OF CREDIT r 8. STATE FUND d CFO LETTER r W. OTHER: <br /> F 3 INSURANCE r 6. EXEMPTION r 9 STATE FUNDS CD 422 <br /> Check one on to indicate which address shouldba used for legal notifications and mailing. 'X. FACILITY r 2. PROPERTY OWNER r 3. TANK OWNER 423 <br /> Le al n.thcah.ns and mailm s will be sent to the tank own unless x 1.r 2 e checked. <br /> Cen4iwtion'. I candy that the information providetl herein is true and accurate to the best dirty knowledge. <br /> SIGNATURE OIF,AgPPFUCANT , DATE 424 PHONE 425 <br /> i cFh°arPAICAf Z pe 4� l.orit rector/Agent 42' <br /> STATE UST FACILITY NUMBER(Forkce/use oni 426 1998 UPGRADE CERTIFICATE NUMBER(For local use oni 429 <br /> UPCF(1/99 revised) 5 Formerly SWRCB Form A <br />