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VIVED PROGRAM CONSOLIDATED FOR <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY o�_ <br /> (One page per site) Page_of �6 <br /> TYPE OF ACTION ❑ 1.NEW PERMIT ❑3.RENEWAL PERMIT ❑5.CHANGE OF INFORMATION ❑7.PERMANENTLY CLOSED SITE 400. <br /> (Check one item only) ®4.AMENDED PERMIT (Specify change)Equipment Modification ❑8.TANK REMOVED <br /> ❑6.TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3. FACILITY <br /> Waterloo Shell q ID! S ' <br /> NEAREST CROSS STREET 401. FACILITY OWNER TYPE ❑4.LOCAL AGENCY/DISTRICT* 402. <br /> Wilcox Rd. ❑ 1.CORPORATION ❑5.COUNTY AGENCY* <br /> BUSINESS ® 1.GAS STATION ❑3.FARM [:15.COMMERCIAL 403. ®2.INDIVIDUAL ❑6.STATE AGENCY* <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR [:16.OTHER ❑3.PARTNERSHIP ❑7.FEDERAL AGENCY* <br /> TOTAL NUMBER OF TANKS 404. Is facility on Indian Reservation 405. *If owner of UST is a p blic agency: name of supervisor of division,section or 405. <br /> REMAINING AT SITE or trust lands? office which operates the UST. (This is the contact person for the tank records.) <br /> 2 ❑Yes ®No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 408. <br /> Bill&Cathie Norby 209-931-3674 <br /> MAILING OR STREET ADDRESS 409, <br /> 4315 Waterloo Rd. <br /> CITY 410. 1 STATE 411. ZIP CODE 412. <br /> Stockton CA 95205 <br /> PROPERTY OWNER TYPE ❑ 1.CORPORATION ®2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 413. <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414, PHONE 415. <br /> Bill&Cathie Norby 209-931-3674 <br /> MAILING OR STREET ADDRESS 415. <br /> 4315 Waterloo Rd. <br /> CITY 417, STATE 418, ZIP CODE 419. <br /> Stockton CA 95205 <br /> TANK OWNER TYPE ❑ 1.CORPORATION 0 2.INDIVIDUAL ❑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 1 1 1 Call(916)322-9669 if questions arise 42 <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ❑ 1.SELF-INSURED ❑4.SURETY BOND ❑7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM 4„ <br /> [12.GUARANTEE ❑5.LETTER OF CREDIT ❑8.STATE FUND&CFO LETTER ❑99.OTHER: <br /> ❑3.INSURANCE ❑6.EXEMPTION [19,STATE FUND&CD <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 owner unless box l or 2 is checked. ❑ 1.FACILITY [:12. PROPERTY OWNER ®3.TANK OWNER 423 <br /> VII.APPLICANT SIGNATURE <br /> Certification: 1 certify that tinformation provided herein is true and accurate to the best of my knowledge. <br /> SIGNATURE 0 P T DATE 424, PHONE 425 <br /> 4/04/05 916-373-1152 <br /> NAME OF PLICANT(print) 425. TITLE OF APPLICANT 427. <br /> Michael Walton Contractor <br /> STATE UST FACILITY NUMBER(Agency use only) 428. 1998 UPGRADE CERTIFICATE NUMBER(Agency use only) 429. <br /> (See Data Element 1,above. <br /> UPCF Hwfwrc-a(1/99)-1/2 http://www.unidocs.org Rev.02/16/00 <br />