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09/05/2003 08:29 2M4F33 FIFTH FLOOR PAGE - 02 <br /> UNIFIED PROGRAM CONSOLIDATED FOTACILITY <br /> PRd:rAo23I488 <br /> FAC A FA6a60 <br /> UND ItGROUND STORAGE TANKS - I 5�vl�d1 b\gu J1 <br /> D �� ��Q� p E t <br /> l' f�1 (en®paga pn ei1" <br /> TYPE OEACTLON ❑ I.N-EW9RE ELRMIT ❑3.RENEWAL PEANR hS�d.dLWC&UE INFDRMgT[ON ❑7-HIMAN�JTLYCLOSMSITE <br /> (CMek Pne itH only) QO.AMFNDlm PERMIT P(, . I <br /> ❑ B.TANK AfiMOVEO <br /> ❑6.TEMPORARY SIT6 CLOsuRE aDe <br /> I.FACILITY)SITE INFORIVIATION ]405 CAIlFORNIA ST,ESCALON <br /> BUSINESSNANWI&+ .uKarrYNu.Ww DNA-Dm,1&Wnm As) 3 FACILITY ID% n <br /> EMIL'S LI OR&SPORTS SI;OP'P FA0000306 PRO231485 <br /> NEARCBI CRO$$$IREET FACILITY WNER Tri>E 4.LOCAL AGENCYlOICTRICT <br /> CALIFORNIA °01 ❑ I.conroA.aT3au ❑s.couNnncFNcr• <br /> EO$A7E95 1.cA5 STATION A'➢IV IDU.AL <br /> TYPE ❑3.FARM EE�l S.COMMkRC1AL ❑ O.STATEAGENCY' <br /> 2.DISTRIRUTOA ❑4PAOCESSOA Ufi,OTI¢tR a95 ❑3�FARTNERSRIP I]T.pCDERAL AGENCY• Ice <br /> TOTAL NUMBER OF TANKS HDeility on Indian llesesvonon or •IEownn orUSTil.P�sEC eCucy:mn=nfuyfreisw arA.;.;aq lec4onwomtt weien opemlec <br /> REMAINING AT SITE mudandd7 iNe UST(lhsxiF:he conks ptrzen 6.mekak rcewde) <br /> a4+ ❑ Yes ®No 4n3 IN <br /> IL PROPERTY OWNER INFORMATION <br /> PROPDRTYOWNEKNAME,J le] PHONE 404 <br /> I�jT ' �- C� n 209 838-7674 <br /> iNNIINO OR STRECT ADD 5 <br /> !S— dl-orV 1c►Jdz-L v-Doof <br /> CITY ao TAIB III ZIP CODE II4 <br /> Rscab T f9-WJ-d,s 4' cA =0. c <br /> PROPERTY OWNER TYPE 1,CORPORATION2.INDIVIDUAL ❑4.LOCAL AGENCY I DISTRICT ❑ 6.STATE AGENCY <br /> kPARTNERSFUP ❑S.COUNTY AGENCY Cl 7.LEDERALAGENCY ala <br /> III.TANK OWNER INFORMATION <br /> TANK OWNERrk at. PHONE <br /> R£ c co "' <br /> ' O/3? S 209 838-7674 <br /> SSS <br /> > 16S Gf7L ►iae � Sd- "< <br /> CITY an 1 blArEala 1 ZIPCODE lip <br /> E AEON ✓ CA ✓ 95320 '-- <br /> TANK WNERTYPE 1 CORPORATION Ioq.I2.94DNMAL 04.LOCAL AGENCY/DISTRICT OaSTATE AGENCY in <br /> ❑ 3.PAR'TNERSFDP ❑S.COUNTY ACiENCY ❑7.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- Call(916)322-9669 if quintioas arise QI <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(3) [7 3.SELF-INSURED ❑A.SURETY BOND 0 7.STATE FUND O 10,LOCALGOVT MECHANISM <br /> ❑2.OUARA.NTEE ❑9.LHTTEII OFCREDIT ❑ s.SPATE FUND&CFO LETTER, W 99.OTHERR <br /> ❑3.INSURANCE ❑6.EXEMPTION ❑ 9.STATE FUND&CD 412 <br /> VL LEGAL NOTIFICATION AND MAILING ADDRESS <br /> mfat Pneloxm uWieate whicOsddess dhfu180e use4 for legll notiReuiondana mailing ® I.FACILITY ❑2.PROPERTY OWNER [2 3.TANK OWNER a23 <br /> LCSal OO-111-d rs m6 plulin wW le sent W*I DO 4-Wi ti lee,ban 1 w 2 k 6"ked J <br /> VH.APPLICANT SIGNATURE <br /> Gm4Calien-I cldil�Chu 4v i.0 idw,mkicd 5ndf%OveaM uw'xRmILe Oeu ffmylmawlsdg. <br /> 91G AAYUKEO IC DATE <br /> NAME OF APPLICANT Ipx ,) 4e0 AN1 427 <br /> STATE UST FACILITY NU3IRER;F-,w1 ppfNyl 421 1998 UPGRADE CERTIFICATE NUMBER ftlp ii ufe fubfIn <br /> k 1998 Compliand V <br /> UPCF(1199 revised) <br />