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D PROGRAM CONSOLIDATED FORM 'L�; U Z PR#i PRO506004 <br /> FAC#:FA0007140 <br /> UNDERGROUND STORAGE TANKS -FACILITY �� <br /> (one page ps <br /> -711q 67-- <br /> TYPE OF ACTION ❑ I.NEW SITE PERMIT ❑ 3.RENEWAL PERMIT 5.CHANGE OF INFORMATION ❑7.PERMANENTLY CLOSED SITE <br /> (Checkoneitemonly) ❑ 4.AMENDED PERMIT ❑ 8.TANK REMOVED <br /> ❑6.TEMPORARY SITE CLOSURE On <br /> I.FACILITY/SITE INFORMATION 6437 W BANNER ST.LODI <br /> BUSINESS NAME(Sginam FACILITYNAMCm DBA-Doing Bmincs As) 3 FACILITY ID# PR IDN <br /> FLAG CITY SHELL le 4(3 j W mwv, FA0007140 PRo506004 <br /> NEAREST CROSS STREET FACILITY OWNER TYPE <br /> BANNER ❑ 4.LOCAL ENCY-STRICT• <br /> 4oi .yi 1.CORPORATION <br /> �❑'s [15.COUNTy'AGENCY* <br /> 2.INDMDUAL <br /> HTORSINESS ® 1.GAS STATION ❑ 3.FARM ❑ 5.COMMERCIAL ❑ 6.STATEAGENCY• <br /> ❑ 2.DISTRIBUTOR ❑ 4.PROCESSOR [16.OTHER 403 [13.PARTNERSHIP ❑ 7.FEDERAL-AGENCY" 402 <br /> TOTALNUMBER OF TANKS Is facility on Indian Reservation of .Yawner of UST is a public agency:name of supervisor of division,section oro6ice which opvmes <br /> REMAINING AT SITE trustlands? The UST(This is the contact person for The tank records.) <br /> 404 ❑ Yes ® N0 405 .NEW WEST PETROLEUM /00 <br /> IL PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 409 <br /> NEW WEST PETROLEUM <br /> MAILING OR STREET ADDRESS <br /> 400 <br /> 1831 16TH ST <br /> CITY 410 1 STATE 911 ZIP CODE 412 <br /> SACRAMENTO CA 95814 <br /> PROPERTY OWNERTYPE ® 1 CORPORATION 02.INDIVIDUAL El 4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY <br /> ❑3.PARTNERSHIF ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY 413 <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414PHONE 415 <br /> NEW WEST PETROLEUM <br /> MAILING OR STREET ADDRESS <br /> 416 <br /> 1831 16TH ST <br /> CITY 417 1 STATE 416 ZIP CODE 419 <br /> SACRAMENTO CA 95814 <br /> TANK OWNER TYPE ® 1.CORPORATION ❑ 2.INDIVIDUAL 04:LOCAL AGENCY/DISTRICT El 6.STATE AGENCY 420 <br /> 113.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TIC)HQ 44- 1 1 Call(916)322-9669 if questions arise 421 <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) . ❑ 1 SELF-INSURED E]4.SURETY BOND ❑ 7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM <br /> ❑2.GUARANTEE ❑5.LETTER OF CREDIT 19 8.STATE FUND&CFO LETTER 1.1 99.OTHER <br /> 1:13.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. ® L FACILITY ❑2.PROPERTY OWNER 1:13.TANK OWNER 423 <br /> Legal notifications and mailing will be sent to the tank owner unless box i or 2 is checked. <br /> VII.APPLICANT SIGNATURE <br /> Certification-1 certify that the inf nvotion provided herein is me and accurate to the best of my knowledge. <br /> SIGNATURE OF APPLIC, T DATE 424 1 PHONE 425 <br /> -710-1C) 12-7 <br /> NAME OF APPLICANT(print) 421 TITLE OF APPLICANT 427 <br /> IA a <br /> ✓z L�kal >r- <br /> STATEUSTFACILITYNUMBER(For 1.1.only) 426 1998 UPGRADE CERTIFICATE NUMBER(FmtooT we noy) 429 <br /> Is 1998 Compliant?Y <br /> UPCF(1/99 revised) <br />