BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

�. YIFIED PROGRAM CONSOLIDATED FORM PR#:PR02313'? ' ' FAC#:FA0003�u 1 F- UNDERGROUND STORAGE TANKS -FAC Cvt (one page per site) TYPE OF ACTION ❑ I.NEW SITE PERMIT ❑3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENTLY CLOSED SITE (Check one item only) ❑ 4.AMENDED PERMIT specify chane twat me - 8only_ '' ❑ 8.TANK REMOVED ❑6.TEMPORARY SITE CLOSURE ., 400 I.FACILITY/SITE INFORMATION 1331 S HAM Ln.LODI BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) gFACILITY ID# PR ID# LODI MUNI SERVICE CENTER FA0003961 PR0231332 NEAREST CROSS STREET FACILITY OWNER TYPE HAM LANE aol ❑ 1.CORPORATION ❑4.LOCAL AGENCY/DISTRICT' El S.COUNTY AGENCY' BUSINESS F] 1.GAS STATION E]3.FARM ® 5.COMMERCIAL ❑ 2.INDIVIDUAL ❑6.STATE AGENCY' TYPE E] 2. 3PARTNERSHIP 402 2.DISTRIBUTOR ❑4.PROCESSOR ❑ 6.OTHER 403 . ❑ 7.FEDERAL AGENCY' TOTAL NUMBER OF TANKS Is facility on Indian Reservation or *If owner of UST is a public agency:name of supervisor of division,section or office which operates REMAINING AT SITE trustlands? the UST(This is the contact person for the tank records.) 404 El Yes ® No 405LODI MUNI SERVICE CENTER 406 II.PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407 PHONE 408 LODI CITY OF 209 334-5634 MAILING OR STREET ADDRESS 409 221 W PINE ST CITY 410 I STATE 411 ZIP CODE 412 LODI CA 95240 PROPERTY OWNER TYPE ❑ I.CORPORATION ❑ 2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY ❑3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY 4 1, III.TANK OWNER INFORMATION TANK OWNER NAME 414 PHONE 41, LODI CITY OF/DENNIS CALLAHAN 209 334-5634 MAILING OR STREET ADDRESS 416 221 W PINE ST CITY 417 1 STATE 418 1 ZIP CODE 419 LODI CA 95240 TANK OWNER TYPE ❑ 1.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 TY(TK)HQ 44- 44-024650 1 Call(916)322-9669 if questions arise 421 V.PETROLEUM UST FINANCIAL RESPONSIBILITY INDICATE METHOD(s) ❑ 1.SELF-INSURED ❑4.SURETY BOND ❑ 7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM ❑2.GUARANTEE ❑5.LETTER OF CREDIT ❑ 8.STATE FUND&CFO LETTER ❑X 99.OTHER ❑3.INSURANCE 1:16.EXEMPTION ❑ 9.STATE FUND&CD 4" VI.LEGAL NOTIFICATION AND MAILING ADDRESS Check one box to indicate which address should be used for legal notifications and mailing. ® 1.FACILITY ❑2.PROPERTY OWNER ❑3.TANK OWNER y�: Legal notifications and mailing will be sent to the tank owner unless box I or 2 is checked. VII.APPLICANT SIGNATURE Certification-I certify that the information provided herein is true and accurate to the best of my knowledge. SIGNATURE OF APPLICANT DATE 424 PHONE 4,; NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 427 STATE UST FACILITY NUMBER(For local ue only) 428 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 Is 1998 Compliant?Y UPCF(1/99 revised)