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�- 0FIED PROGRAM CONSOLIDATE RM <br /> TANKS I, <br /> I <br /> UNDERGROUND STORAGE TANKS - FACILITY (one page per site) <br /> Page of _ <br /> TYPE OF ACTION I. 1.NEW SITE PERMIT r 3.RENEWAL PERMIT F 5,CHANGE OF INFORMATION(Sp fy change- }C B.TANK R7. EMOVED CLOSED SITE <br /> r <br /> (Check one Item only) a.AMENDED PERMIT local use only) <br /> )'6.TEMPORARY SITE CLOSURE <br /> I.FACILITY/SITE INFORMATION <br /> FAcluTv ID x <br /> BUSINESS NAME(Same as FACILITY NAME or DBA.Doing Business As) 3 ; <br /> SSoseRb E. Fro Ji�er <br /> Froe11 er MHC In Tool Co FAO NME 4Y8PE [ 4. LOCAL AGENCY/DISTRICT <br /> NEAREST CROSS STREET 40t [- 1. CORPORATION r 5. COUNTY AGENCY' <br /> Between "A" and Filbert Sts ) S. STATEAGENCY' <br /> BUSINESS TYPE [' 1.GAS STATION I' 3.FARM T S.COMMERCIAL FX2. INDIVIDUAL <br /> r 2.DISTRIBUTOR r 4.PROCESSOR r 6,OTHER r 3. PARTNERSHIP r 7. FEDERAL AGENCY- 402 <br /> 403 <br /> TOTAL NUMBER OF TANKS Is fae4iry on Indian Reservation or -If owner d UST is a pualW agency:name of supenwor o1 <br /> REMAINING AT SITE rrustlands7 division.section or office whk,operates the UST. <br /> (This is Ne contact person for the tank recoras.) <br /> 464 0 after re ovgliat TNp 405 406 ' <br /> if.PROPERTY OWNER INFORMATION <br /> PHONE 408 i <br /> PROPERTY OWNER NAME 407 290-948-2888 <br /> Joseph E. Froeli er <br /> MAILING OR STREET ADDRESS 4ou <br /> STATE 4N ZIP COD 412 <br /> °1Y a10 CA 95205 <br /> Stockton [ 4 LOCAL AGENCY I DISTRICT L 6. STATEAGENCY 413 <br /> PROPERTY OWNER TYPE 2. INDIVIDUAL <br /> ]' 1. CORPORATION [' 3. PARTNERSHIP C 5. COUNTY AGENCY I 7. FEDERAL AGENCY <br /> III.TANK OWNER INFORMATION <br /> PHONE 415 <br /> TANK OWNER NAME 414 <br /> Same as property owner <br /> MAILING OR STREET ADDRESS 416 <br /> STATE 418 ZIP CODE 419 <br /> CITY 417 <br /> TANK OWNER TYPE C- 2. INDIVIDUAL 4. LOCAL AGENCY I DISTRICT C 6. STATE AGENCY 420 <br /> 1. CORPORATION [' 3. PARTNERSHIP r 5. COUNTY AGENCY I 7. FEDERAL AGENCY <br /> TY(TK)HQ 4 4 - <br /> Call(916)322-9669 if questions arise 421 <br /> AN <br /> INDICATE METHOD(S) 1. SELF-INSURED C 4. SURETY BOND F 7. STATE FUND C 10. LOCAL GOV=T MECHANISM <br /> P 2. GUARANTEE r 5. LETTER OF CRE01T r a. STATE FUND 8 CFO LETTER I Be. OTHER: 422 <br /> r 3. INSURANCE C 6. EXEMPTION I- 9. STATE FUND&CD <br /> Ch ll ba 1 d t Ach address should l0iri In keds leg unless <br /> tons TSW�Mailing. <br /> r 1 FACILITY r 2. PROPERTY OWNER r 3. TANK OWNER 423 <br /> ftE <br /> 1R d 1 <br /> I <br /> Ceddiamion: I certify that the information wowae0 herein is true and accurate to Ne best Of my knoiledge. 425 <br /> SIGNA EOFAPPLI DATE 424 POj4F„-948-2888 <br /> 425 I APL ANT 427 <br /> NAME APPLI NT(Print) <br /> STATE UST FACILITY NUMBER(Forlocal use only) <br /> 428 1998 UPGRADE CERTIFICATE NUmucm(For klcal use only) 429 <br />