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rZ61 vs�'zLX- �NIFIED PROGRAM CONSOLIDATED FOR?* PR#:PR0507806 <br /> FAC#:FA0007770 <br /> UNDERGROUND STORAGE TANKS - FACILIT Z <br /> /q (one page r ) <br /> TYPE OF ACTION ❑ 1.NEW SITE PERMIT ❑ 3.RENEWAL PERMIT ❑ ; CrIkNGE OF INFORM\TION ❑❑ ].PERMANENTLY CROV101 <br /> ITE <br /> (Check one item only) ❑4,AMENDEDPERMIT spam'I yI d�mwtl} __ 8.TANKREMOVED <br /> ❑ b TEMPORARY SITE(LOSLRL Aql <br /> L FACILITY/SITE INFORMATION 6364 LINDBERGH ST 202,STOCKTON <br /> BUSINESS NAME(store as FACILITY NAME.,DBA-Doing Has.,As7 3 FACILITY ID# PR ID# 1 <br /> FLIGHT SUPPORT FA0007770 PRO507806 <br /> NEAREST CROSS STREET FACILITY OWNER TYPE ❑ 4.LOCAL AGENCY/DISTRICT' <br /> 401 <br /> ® I.CORPORATION ❑ 5.COUNTY AGENCY* <br /> BUSINESS ❑ 2.INDIVIDUAL .❑ 1.GAS STATION ❑ 3.FARM ❑ 5.COMMERCIAL E:1 3 PARTNERSHIP ❑ 6STATE AGENCY' 402 <br /> TYPE <br /> F12.DISTRIBUTOR ❑ 4.PROCESSOR F-16.OTHER 403 ❑ ].FEDERAL AGENCY" <br /> TOTAL NUMBER OF TANKS Is facility on Indian Reservation or 'If owner of UST is public agencyname of supervisor of division.section or office which operates <br /> RENAMING AT SITE [rustlands? the UST(This is the contact person for the tank records.) <br /> 406 <br /> 404 ❑ Yes M No d05 <br /> II.PROPERTY OWNER INFORMATION <br /> PROP ERTYOWNER NAME 412 PHONE 408 <br /> 209 4684700 <br /> 409 <br /> MAILING OR STREET ADDRESS <br /> 5800 S AIRPORT WY#202 STATE Z P CODE rz <br /> CITY 410 <br /> STOCKTON CA 95206 <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 /> III.TANK OWNER INFORMATION <br /> TANK RNAME 414 PHONE 415 <br /> FLIGHT SUPPORT 209 957-4119 <br /> MAILING OR STREET ADDRESS 416 <br /> 6120 LINDBERG ZIP CODE 9 <br /> CITY 411 STATE 418 <br /> STOCKTON CA 95206 <br /> TANK OWNER TYPE ❑X I.CORPORATION ❑ 2.INDIVIDUAL ❑ 4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY 420 <br /> ❑ 3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 44-038880 <br /> Call(916)322-9669 if questions arise 431 <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) X❑ I.SELF-INSURED ❑4.SURETY BOND ❑ 7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM <br /> ❑2.GUARANTEE ❑ 5.LETTER OF CREDIT ❑ 8.STATE FUND&CFO LETTER ❑99.OTHER <br /> ❑3.INSURANCE ❑6.EXEMPTION ❑ 9.STATE FUND&CD 422 <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 03.TANK OWNER 423 <br /> Legal notifications and mailing will be sent to the tank owner unless box 1 or 2 is checked. <br /> VH.APPLICANT SIGNATURE <br /> Certification.I certify that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNATURE OF APPLICANT DATE 424 PHONE 4zs <br /> NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 427 <br /> STATE UST FACILITY NUMBER IFor and uv om>7 <br /> 423 1998UPGRADECERTIFICATENUMBER(Forlwoluwmb) 029 <br /> Is 1998 Compliant?Y <br /> UPCF(1/99 revised) <br />