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VIAIFIFD PROGRAM CONSOLIDATED FOR1At <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page per site) PER,J-of J- <br /> TWE OF ACTION 1.NEW SITE PERMIT 3.RENEWAL PERMIT 0 5.CHANGE OF INFORMATION ❑ 7.PERMANENTLY CLOSED SITE <br /> (Check am item muly) [14.AMENDED PERMIT specify change local use only ❑ IL TANK REMOVED <br /> ❑&TEMPORARY SITE CLOSURE aro I' <br /> 1. FACILITY/SITE INFORMATION Il S hZ <br /> BUSINESS NAME(Smme ms FACILITY NAME m DBA-Da.Bs ime As) 3 FACILITY 11 : /1 <br /> San Joaquin I?e ;DnaL Transll" bisirict 3 7 <br /> NEAREST CROSS STREET ,y, 401 FACUM OWNER TYPE 4.LOCAL AGENCY/DISTRICT" <br /> X3-3 Qnd5ay Street ❑ 1.CORPORATION ❑S.COUNTY AGENCY' <br /> BUSINESS 0 1.GAS STATION ❑3.FARM L1 5. COMMERCIAL. ❑ 2.INDIVIDUAL [:16.STATE AGENCY" ` <br /> TYPE ❑2.DISTRIBUTOR [14.PROCESSOR❑6. OTHER 403 ❑ 3.PARTNERSHIP ❑7.FEDERAL AGENCY" m2 <br /> TOTAL NUMBER OF TANKS Is facility on Indian Reservation or "if..f UST is a public ap.y:name of pi.,.f divivm,sectiae a ofics whkh <br /> REMAINING AT SITE nostlands? operates the UST(This is the contact person for the tank retook.) <br /> SWen `� 4a ❑ Yet ® No '146 W. Sobb kuhn 4M <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 4m PHONE 4os <br /> SM "Todqu'ln Re9ionciLTransrE bisi-ric7 209-94$- 5566 <br /> MAILING OR STREET ADDRESS 4m <br /> 1533 E. L;ndSa 5ir4 t <br /> CITY Sibc10bn 410 1 STATECA <br /> 411 1 ZIP CODE g5205- 44.98 412 <br /> PROPERTY OWNER TYPE 0 1.CORPORATION M 2.INDIVIDUAL 2N 4.LOCAL AGENCY/DISTRICT U&STATEAGENCY <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY 413 <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> SanJoaqu�n R? jicn LTretn4 D�sfricZ 209-948-5566 <br /> MAILING OR STREET ADDRESS 414 <br /> /533 Ey._ 44&Sn 5-redt <br /> CITY Sfiock /Un 417 1 STAT^ 419 1 ZIP CODE g590.5 419 <br /> TANK OWNER TYPE 1.CORPORATION EI 2.INDIVIDUAL )A 4.LOCAL AGENCY/DISTRICT 'l6.STATE AGENCY 420 <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY K HQ 44- 10 12 14161 616 Call 916 322-9669 if questions arise 421 <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) 1.SELF-INSURED [14-SURETY BOND [17.STATE FUND ❑10.LOCAL.GOVT MECHANISM <br /> ❑2.GUARANTEE [15.LETTER OF CREDIT ❑8.STATE FUND&CFO LETTER ❑ 99.OTHER: <br /> ❑3.INSURANCE ❑6.EXEMPTION ❑9.STATE FUND&CD 4n <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Chink ort box to indium which address should be used for legal mdfiutions and mailing. <br /> LSW nonficatiam and mailing,will be mt to the tank owner unless box l or 2 is checked. ❑ 1.FACILITY ❑2. PROPERTY OWNER )$3.TANK OWNER 4D <br /> VII.APPLICANT SIGNATURE <br /> CettiRcmi it, k mm and akvumts m the beat of my kmwlWp. <br /> SIG OF ANT DATE 424 PHO ass <br /> 03 S 20o2 «1-94-8-5566 <br /> OF AP (print) 06 TITLE OF APPLICANT 427 <br /> y Kuhn LYrec}br of MaintellanCe <br /> STATE UST FACILITY NUMBER(Fra loml are arty) 42a 1998 UPGRADE CERTIFICATE NUMBER(For lama sae arty) 41 <br /> UPCF(1/99 revised) 8 Formerly SWRCB Form A <br />