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NIFIED PROGRAM CONSOLIDATED FOR Lpage PR#:PR0232509FAC#:FA0003731 UNDERGROUND STORAGE TANKS - FACILITYoy TYPE OF ACTION ❑ I.NEW SITE PERMIT ❑ 3.RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7.PERMANENTLY CLO ED`TE 8.TANK REMOVED (Check one item only) ❑ 4.AMENDED PERMIT ❑ \� ✓ �� ; ❑6.TEMPORARY SITE CLOSURE IF 400 CID I.FACILITY/SITE INFORMATION 11919 N LOWER SACRAMENTO RD,LODI BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) g FACILITY ID# I PR ID# PRECISSI FLYING SERVICE FA0003731 PR0232509 NEAREST CROSS STREET FACILITY OWNER TYPE ❑ 4.LOCAL AGENCY/DISTRICT- LOWER SACRAMENTO 401 El I.CORPORATION ❑ 5.COUNTY AGENCY* BUSINESS ❑ 1.GAS STATION ❑ 3.FARM ❑ 5.COMMERCIAL ❑ 2.INDIVIDUAL ❑ 6.STATE AGENCY* TYPE ❑ ❑ 3PARTNERSHIP 402 2.DISTRIBUTOR ❑ 4.PROCESSOR ❑ 6.OTHER 403 . [:17.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 ❑ Yes N No 403 PRECISSI FLYING SERVICE 406 II.PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407 PHONE 408 209 369-6945 MAILING OR STREET ADDRESS 409 11919 N LOWER SACRAMENTO CITY 4111 STATE 411 ZIP CODE 412 LODI CA 95240 PROPERTY OWNER TYPE ® 1.CORPORATION ❑ 2.INDIVIDUAL ❑ 4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY ❑3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY 413 III.TANK OWNER INFORMATION TANK OWNER NAME ala PHONE 415 PRECISSI FLYING SERVICE 209 369-6945 MAILING OR STREET ADDRESS 416 11919 N LOWER SACRAMENTO CITY 417 STATE 418 1 ZIP CODE 419 LODI CA 195240 TANK OWNER TYPE ❑X 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- 1 44-033821 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 112.GUARANTEE ❑5.LETTER OF CREDIT ❑ 8.STATE FUND&CFO LETTER N]99.OTHER ❑3.INSURANCE ❑6.EXEMPTION ❑ 9.STATE FUND&CD 422 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 423 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 1 PHONE 425 NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 427 STATE UST FACILITY NUMBER(For local w only) 428 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 Is 1998 Compliant?Y UPCF(1/99 revised)