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sUWED PROGRAM CONSOLIDATED FOR41 <br /> 8 G pj <br /> TANKS <br /> 14DERGROUND STORAGE TANKS - FACIL,IT it 8/Seo <br /> (One nage per site) Page_of <br /> TYPE OF ACTION [IE L NEW i FRMIT ❑3.RENEWAL PERMIT ❑5.CHANGE OF INFORMATION [17.PERMANENTLY CLOSED SITE 400. <br /> (Check one item only) ❑4.AMENDED PERMIT (Specify change) ®8.TANK REMOVED <br /> ❑6.TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION <br /> BUSINESS NAME(same es FACILITY NAME or DBA-Doing Business As) 3. FACILfITAY <br /> 90 MOUNT OSO STREET BENJAMIN PROPERTY I �o <br /> NEAREST CROSS STREET sol. FACILITY OWNER TYPE ❑4.LOCAL AGENCY/DISTRICT• 4o2. <br /> CENTRAL AVENUE [11.CORPORATION ❑5.COUNTY AGENCY* <br /> BUSINESS ❑ 1.GAS STATION ®3.FARM ❑5.COMMERCIAL 403, Z 2.INDIVIDUAL [16.STATE AGENCY* <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR ❑6.OTHER [-13.PARTNERSHIP ❑7.FEDERAL AGENCY* <br /> TOTAL NUMBER OF TANKS 404. Is facility on Indian Reservation 405. 4I owner of UST is a public agency: name of supervisor of division,section or 406. <br /> REMAINING AT SITE or trust lands? office which operates the UST. (This is the contact person for the tank records.) <br /> 0 ❑Yes Z No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 408, <br /> DANNY BENJAMIN 209-830-9712 <br /> MAILING OR STREET ADDRESS 409, <br /> 1381 FRUITWOOD WAY <br /> CITY 410. STATE 411. ZIP CODE 412, <br /> TRACY CA 95376 <br /> PROPERTY OWNER TYPE ❑ 1.CORPORATION Z 2.INDIVIDUAL [-14.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 413' <br /> ❑3.PARTNERSHIP [15.COUNTY AGENCY [-17.FEDERAL AGENCY <br /> M. TANK OWNER INFORMATION <br /> TANKOWNERNAME 414. PHONE 415. <br /> DANNY BENJAMIN 209-830-9712 <br /> MAILING OR STREET ADDRESS 416_ <br /> 1381 FRUITWOOD WAY <br /> CITY 417. STATE 418. ZIP CODE 419. <br /> TRACY CA 95376 <br /> TANK OWNER TYPE ❑ L CORPORATION Z 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- 1 1 1 1 Call 916 322-9669 if questions arise 421 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ❑ 1.SELF-INSURED ❑4.SURETY BOND [17.STATE FUND [110.LOCAL GOVT MECHANISM 422 <br /> ❑2.GUARANTEE ❑5.LETTER OF CREDIT [18.STATE FUND&CFO LETTER ❑99.OTHER: <br /> ❑3.INSURANCE ❑6.EXEMPTION [19.STATE FUND&CD <br /> VI. LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one box to indicate which address should be used for legal notifications and mailing. <br /> Legal notifications and mailings will be sent to the tank owner unless box 1 or 2 is checked. ❑ 1.FACILITY Z 2. PROPERTY OWNER [13.TANK OWNER 423. <br /> VII. APPLICANT SIGNATURE <br /> Certification: 1 certify that the information provided herein is true and accurate to the best of my knowledge. <br /> ATURE OF PLICANT DATE 424. PHONE 425, <br /> 07 JULY 2003 209-467-1006 <br /> AME OF LICANT(print) 426. TITLE OF APPLICANT 427 <br /> DANNY BENJAMIN OWNER <br /> STATE UST FACILITY NUMBER(Agency use only) 428. 1998 UPGRADE CERTIFICATE NUMBER(Agency use only) 429' <br /> (See Data Element 1,above. <br /> UPCF Hwfcvrc-a(1/99)-1/2 http://www.unidoes.org Rev.02/16/00 <br />