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UNIFIED PROGRAM CONSOLIDATED FORM <br />UNDERGROUNDSTORAGETANK <br />OPERATING PERMIT APPLICATIONINFORMATION (one fiorm per UST) <br />-INFORMATION <br />FACILITY 11) # (Agenty use Only) <br />BUSINESS NAME (Some as Focih�;,.Vame or DBA Doing Bmfiness,4s) <br />USA/Tesoro 68151 <br />BUSINESS SITE ADDRESS 103 <br />CITY <br />104- <br />35 N. Cherokee Lane <br />Lodi <br />glints EM111111UN&WIV <br />DATE USTSYSTEM INSTALLED 435 <br />TANK CAPACITY) GALLONS 436 <br />1HIM"i H&RAM 1m191;01WI1 <br />1995 <br />1 0,r 00 <br />■ <br />tag= <br />*4 <br />11"R X I's <br />MOTECTION <br />— <br />4, IMPRESSED CURRENTly6. ISOLA-r10N <br />448 <br />S <br />APPLICANTSICiNATURE <br />APPLICANT NAME (print) Sandy Edwards 471 <br />UPCF UST -6 Rev, (12/2007)-1/2 www.unidOCLorg <br />