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Jul 27 04 11:59a Val'- Paoific 120994755 p•3 <br />UNIFIED PROGRAM CONSOLIDATED FORM <br />TANKS <br />UNDERGROUND STORAGE TANKS - FACILITY <br />(nn0 P0Sa I°x aiW) P:rga _•d <br />TYPI, OF AC1,loN ❑ I. NEWSI'MPERMIT 03.REM."NALPLRMR H5.CIIAN0k0l;INIQIIfMA'I'IUN l.l'b:ItMANI(N'I'LV f:LOSI{U NI'I'h. <br />(Check one item only) ❑4. AMENDED PERMIT spotify change local use only. ..-., . ❑ I. TANK 101MOVrn <br />❑ 4: I'h'M ULARY SIT H CLOSU1W 400 <br />1.� FACILITY I SITE. INFORMATION <br />MISINI(SS NAMR l,oa,m PACIITII NM4r.nr,11A.-Cm,"omhlcn Aa) ] FACII-fl'Y lll!! .,: 1 <br />Jocs Su crslo indcn M irkct __ <br />101 �FACILITYOWNHR'rYP73 4. IjAI, ACIRNCY/DISTRICT- <br />NLAK1iST Cams 'Fit 171'. r <br />❑ 1. CORPolw'I(7N ❑ 5. C(711NTY AGENCY' <br />A)P�G <br />UUSINI(SS N I. (IAS Y1,%I ❑ 3. FARM ® 5. COMMLKC1AL ® 2. INDIVIDUAL ❑ 6.5'I'A'1'R ACiI!NCY" <br />TYPR ❑ 2. DISTRILAITUR ❑ 4. PROCLSSUR ❑ f. (YI'H1)R del O T, PAR7NLRSl1W ❑ 7. FLDIsAAL AGF•,NCY- 4lst <br />TY7tA).NTtMLiFR OFTANKS <br />Iaksdlilyw Indian ltctwrvatianM <br />•'ll,wnur n:'llS'I',x it Puhlin aSenq n,vrc nl'aul+ervrxnr nl'dmmml, vrnlm vnnlw which <br />nlwruex the e51'('Ifiin ix Jw -,muted Panum fnr uw, w1ft rec,adx ) <br />RISM,UN ING A'1' 4111( <br />Inu4lamla7 <br />9 nal <br />❑ Yea ® NO nos <br />._.._ Aaa <br />II. PROPERTY OWNER iNFORMATION <br />PROPLR'FY OWNLKNAML r-� 'a PIIUNli ma <br />Amar it Sin (209) 948-4911 <br />4N <br />MAILING UR S'1'RLE'r ADDRESS <br />.- 0ft CAun. -Club Blvd <br />•CLT'Y 410 ghgT•p; 411 '/II'GY)I715 412 <br />195204 <br />Stockton CA <br />pR(1I'RR'IY OWNER'I'Y1'R I. COI&ORIMON 2. INDIVIDUAL 4. 1 MAI. ACIICNCY/Dnrl'RI("I' 6. S'I'A'I'h:AGI•;NCY <br />❑ 3. YARTNISRSHIP ❑ 5. CX)IIN'IY .A0t NCY 7, 7-T )FRAI. AU]iNCY 419 <br />M. TANK OWNER INFORMATION <br />'YANK 0WN1iR NMAE W 414 1'l1UNE q11 <br />b lzo9>9as a9n <br />457- <br />AnTarlit Sin'Itlil;'1' <br />UR AI]DRI'SS <br />HALING S'I <br />3(x)G Country Club Blvd <br />CITY m S'I'NIT 4111 %IP conn A19 <br />Stockton CA 95204 <br />TANKOWNI.RTYl'IC LWRI'(7RA'l'!ON 2. INDIVIDUAL. 4,IA]OAL,A0RYCY/DINTRIUI' 6.S'rNI'EA(1LNCY nil <br />❑ 3. PARTNRR81111, D 3, COUNTY AOLNCY ❑ 7. ITiDI:RAf _AGP:NCY <br />IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br />T'Y ('fIC) H 44- .- Call (916) 322 ')G(7'1 if qu(Tstions arise <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br />INllICATL Mli'!'1(OD(a) ❑ 1. SP:1.Ir-INSUW?I] ❑ 4, SUR1:T' DONll ❑ 7. S'rA'fli FUND ❑ In. LOCAL GOVT MI'CIIANISM <br />❑ 2. GUAdANTTSR ❑ 5. T FTl'f>R or CRIAIT' ® S. STATE FUND & CPO UA -ITR ❑ 99. (Yrrn<R:__ <br />[].3. INSURANCL ❑ 6. liXnMPTTUN ❑ 9, STATL•' FUND & CD ata <br />Vl. LEGAL NOTIFICATION AND MAILING ADDRESS <br />Chock 0110 bsxto iCAicele which 2Annx nlnmld ha .,ml fnrle,.A n,nifiouli0na aM maiWg. .-, <br />lwgal twtifiowmx and m,dhnhe will hc:rmm the wk owneran1m boa l or 2 is dn,,kd. ❑I. FAMI.I'1'V rl 7. PROPli7l'1'Y OWNUR 19 3. TANKOWNGR 427 <br />VIL APPLICANT SIGNATURE <br />�• <br />Catwe1i1ou- l wilily that thu inl'nrinwrm wwided herein is Vee andnecurala W lhubsA nl'my kmrwladgo. <br />SIONli URL•' OF AYYLICAN'1' <br />DA IT: '12n 1a110NIS 4a <br />42 <br />NAMF: OF'AI'PLIC N'I'(prird) '•2a <br />TMA OF APPTICANT' <br />'�,, <br />YA pr ti, a <br />N'I'KIL USI'FACILI'IYNU Ill':R (Ym kwxllaa ony) oar <br />I%UYORAUE CWf1'L74A'1'B NUMIih:R p'nr kxahw only) '� <br />