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f NIFIED PROGRAM CONSOLIDATED c q /! /�J PR#: I I 0) FAC#:I UNDERGROUND STORAGE TANKS -FAC a(-�1/, (one page per site) TYPE OF ACTION ❑ 1.NEW SITE PERMIT ❑ 3.RENEWAL PERMIT ^A (Check one item only) ❑ 5.CHANGE OF INFORMATION ❑ 7•PERMANENTLY CLOSED TE J ❑ 4.AMENDED PERMIT specify change local u e only ❑ 8.TANK REMOVED ❑6.TEMPORARY SITE CLOSURE (,'� 12 1.FACILITY/SITE INFORMATION 1331 S HAI Ln.LODI ((( BUSINESSNAIE(Same asFACILITY NAME orDBA.DoingBusiness.Ysl 3 FACILITY ID# PR ID# LODI MUNI SERVICE CENTER FA0003961 PR0231332 1 NEAREST CROSS STREET FACILITY OWNER TYPE HALM LANE 401 ❑ I.CORPORATION ❑4•LOCAL AGENCY/DISTRICT* BUSINESS [j 5.COUNTY AGENCY- TYPE F1I GAS STATION ❑ 3.FARM ® 5.COMMERCIAL ❑ 2.INDIVIDUAL ❑ 6.STATE AGENCY* ❑ 2.DISTRIBUTOR ❑ 4.PROCESSOR ❑ 6.OTHER 403 ❑ 3•PARTNERSHIP ❑ 7.FEDERAL AGENCY- i0 TOTAL NL"MBER OF TANKS Is facility on Indian Reservation or REMAINING AT SITE trustlands? *Ifowner of UST is a public agency:name of supervisor ofdivision,section or office which operates the UST(This is the contact person for the tank records.) 404 ❑ Yes ® No 105 LODI MUNI SERVICE CENTER 406 If. PROPERTY OWNER INFORMATION PROPERTY O«'NER NAME 407 PHONE LODI CITY OF 40s MAILING OR STREET ADDRESS 209 334-5634 221 W PINE ST 409 CITY 410 STATE 411 ZIP CODE LODI 412 PROPERTY O%� TYPE CA 95240 ❑ I.CORPORATION ❑ 2.INDIVIDUAL ❑ 4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY El 3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY 41= Ill.TANK OWNER INFORMATION TANK ON%NER NAME 414 LODI CITY OF/DENNIPHONE 4tsS CALLAHAN 209 334-5634 MAILING OR STREET ADDRESS 221 W PINE ST 416 CITY LODI 41; STATE 418 ZIP CODE 419 CA 195240 FTANKER Tt'PE ❑ I.CORPORATION ❑ 2.INDIVIDUAL ❑ 4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY 420 ❑ 3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER Q 44- 44-024650 Call(916)322-9669 ifquestions arise 421 V.PETROLEUM UST FINANCIAL RESPONSIBILITY INDICATE METHOD(s) ❑ I.SELF-INSURED ❑4.SURETY BOND ❑ 7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM 1:11 GUARANTEE ❑ 5.LETTER OF CREDIT ❑ 8.STATE FUND&CFO LETTER 99.OTHER ❑3.INSURANCE ❑6.EXEMPTION ❑ 9.STATE FUND&CD 411 VI.LEGAL NOTIFICATION AND MAILING ADDRESS Check one bo,,to indicate which address should be used for legal notifications and mailing. ® I.FACILITY ❑2.PROPERTY OWNER ❑3.TANK OWNER J23 Legal notifications and mailing will be sent to the tank owner unless box I or 2 is checked. VI1.APPLICANT SIGNATURE Certification•I certifi that the information provided herein is true and accurate to the best ofmy knowledge. SIGNATURE OF APPLICANT DATE 424 PHONE 42i 426 NAME OF APPLICANT(print) TITLE OF APPLICANT 42; STATE UST FACILITY NUMBE R,For local.only) 429 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 Is 1998 Compliant?Y UPCF(1-99 revised)