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TIED PROGRAM CONSOLIDATED FORW <br /> 1111111-ie TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page per site) Page_of <br /> TYPE OF ACTION ❑ I.NEW SITE PERMIT [13.RENEWAL PERMIT ®5.CHANGE OF INFORMATION ® 7.PERMANENTLY CLOSED SITE <br /> (Check one item only) ❑4.AMENDED PERMIT specify change local use only ❑ 8.TANK REMOVED <br /> ❑6.TEMPORARY SITE CLOSURE 400 <br /> I. FACILITY/ SITE INFORMATION <br /> BUSINESS NAME(sane m FACILITY NAME or DBA-Doing Bmmemm Aa) 3 FACILITY ID# <br /> s.y 0 0 6 1 3 6 1 <br /> Penske Truck Leasing Co. L.P. <br /> NEAREST CROSS STREET 401 FACILITY OWNER TYPE ❑4.LOCAL AGENCY/DISTRICT' <br /> 1950 East Miner Road, Stockton,CA 95205-4554 ® L CORPORATION ❑5.COUNTY AGENCY' <br /> BUSINESS 1.GAS STATION 3.FARM 5. COMMERCIAL ❑ 2.INDIVIDUAL ❑6.STATE AGENCY' <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR®6. OTHER 403 ❑ 3.PARTNERSHIP ❑7.FEDERAL AGENCY" 402 <br /> TOTAL NUMBER OF TANKS Is facility on Indian Reservation or 'If owner ofUST is a public agency:name of supervisor of division,section or office which <br /> REMAINING AT SITE tnmtlands? operates the UST(This is the contact person for the tank records.) <br /> 0 404 ❑ Yes ® No 405 406 <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408 <br /> Port Stockton Foods Distributors,INC <br /> MAILING OR STREET ADDRESS 409 <br /> 4343 E.Fremon Street <br /> CITY 410 STATE 411 ZIP CODE 412 <br /> Stockton CA 95215 <br /> PROPERTY OWNER TYPE OLCORPOPATION 2.INDIVIDUAL U 4.LOCAL AGENCY/DISTRICT Lj 6.STATE AGENCY <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY 413 <br /> M. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> Penske Truck Leasing Co.,INC 610-775-6406 <br /> MAILING OR STREET ADDRESS 416 <br /> Route 10,Green Hills, P. O.Box 7635 <br /> CITY 417 STATE 418 ZIP CODE 419 <br /> Reading PA 19603-7635 <br /> TANK OWNER TYPE ffl.CORPORATION 2.INDIVIDUAL Lj 4.LOCAL AGENCY/DISTRICT 6.STATE AGENCY 420 <br /> [13.PARTNERSHIP [15.COUNTY AGENCY 7.FEDERAL AGENCY <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY TK HQ 44- 1 0 10 10 1 5 14 Call 916 322-9669 if questions arise 421 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ® 1.SELF-INSURED ❑4.SURETY BOND ❑7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM <br /> ❑2.GUARANTEE ❑S.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. <br /> Legal notifications and mailings will be sent to the tank ownerless box 1 or 2 is checked. ❑ 1.FACILITY [12. PROPERTY OWNER N 3.TANK OWNER 423 <br /> VII. APPLICANT SIGNATURE <br /> Certification-I certify that th information provided herein is true and accurate to the best of my knowledge. <br /> SIGNATURE OF APP DATE 434 1 PHONE 425 <br /> 01/30/02 610-775-6406 <br /> NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 427 <br /> Andrew E.Cullen Director Envimmental Sevices <br /> STATE UST FACILITY NUMBER(For 1ocv1 me only) 428 1998 UPGRADE CERTIFICATE NUMBER(For local van only) 429 <br /> UPCF(1/99 revised) 8 Formerly SWRCB Form A <br />