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IFIED PROGRAM CONSOLIDATED FOR PR#:PRO506004 FAC#:FA0007140 UNDERGROUND STORAGE TANKS - FACILITY (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 ❑ 8.TANK REMOVED ❑6.TEMPORARY SITE CLOSURE 400 I.FACILITY/SITE INFORMATION 6437 W BANNER ST.LODI BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 FACILITY ID# PR IDI FLAG CITY SHELL* FA0007140 PR0506004 1 NEAREST CROSS STREET FACILITY OWNER TYPE E] 4.LOCAL AGENCY/DISTRICT° BANNER 401 ® 1.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 ao3 ❑ 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 ❑ Yes ®No 405 406 II.PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 41 PHONE 408 916 443-0890 MAILING OR STREET ADDRESS 409 1831 16TH ST CITY 410 STATE 411 ZIP CODE 412 SACRAMENTO CA 95814 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 414 PHONE 415 MOORE,J GILBERT (916)443-0890 MAILING OR STREET ADDRESS 416 1831 16TH ST CITY 417 1 STATE als ZIP CODE 419 SACRAMENTO CA 95814 TANK OWNER TYPE ® 1.CORPORATION ❑ 2.INDIVIDUAL ❑ 4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY 420 ❑ 3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY TANK OPERATOR INFORMATION TANK OPERATOR NAME TANK OPERATOR TITLE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY(TK)HQ 44- 44-036163 F 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 ❑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. El 1.FACILITY ©2.PROPERTY OWNER ❑3.TANK OWNER 423 Legal notifications and mailing will be sent to the tank owner unless box 1 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 (916)443-0890 NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 427 J GILBERT MOORE OWNER 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)