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le-lo-D <br /> 'IFIE/DgPR�(�G3 M CONSOLIDATED FORM/ PR#: R023220 <br /> � 03 FAC M FAW03767 <br /> UNDkGROUND STORAGE TANKS -FA <br /> U a �� <br /> (one page per site) <br /> TYPE OF ACTION ❑ 1.NEW SITE PERMIT ❑ 3.RENEWAL PERMIT ❑ S.CHANGE OF INFORMATION ❑ 7.PERMANENTLY C OSED S <br /> (Check one item only) ❑ 4.AMENDED PERMIT ❑ 8.TANK REMOVE <br /> ❑6 TEMPORARY SITE CLOSURE 9I D 400 <br /> 1.FACILITY/SITE INFORMATION 1819 S ARGONAUT ST.STOCKTON <br /> BUSINESS NAME(sameu FACILOT NAME orDIM-cost,ommas Aa) 3FACII7TYmk PRID# <br /> JOHN TAYLOR FERTILIZER* FA0003767 PR0z3zozo <br /> NEAREST CROSS STREET FACILITY OWNER TYPE ❑ 4.LOCAL AGENCY/DISTRICT' <br /> ARGONAUT 401 ❑ 1.CORPORATION ❑ 5.COUNTY AGENCY' <br /> BUSINESS ❑ 2.INDIVIDUAL <br /> ❑ 1.GAS STATION ❑ 3.FARM ❑ 5.COMMERCIAL ❑ 6.STATE AGENCY' <br /> TYPE ® 2.DISTRIBUTOR ❑4.PROCESSOR ❑ 6.OTHER 403 ❑ 3.PARTNERSHIP ❑ 402].FEDERAL AGENCY' <br /> TOTAL NUMBER OF TANKS Is facility on Indian Reservation or *Ifowner of UST is a Public agency:name of supervisor ofdivision,section or office which operates <br /> REMAINING AT SITE trustlands? the UST(This is the contact Person for the tank records.) <br /> <� ❑ Yes ® No 405JOHN TAYLOR FERTILIZER 406 <br /> 11.PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 402 PHONE 408 <br /> TAYLOR-WISEMAN DIVISION 209 944-9951 <br /> MAILING OR STREET ADDRESS 409 <br /> 1819 S ARGONAUT <br /> CITY 410 STATE 411 ZIP CODE 412 <br /> STOCKTON I CA 95206 <br /> PROPERTY OWNER TYPE ❑ I.CORPORATION ❑ 2.INDIVIDUAL ❑4.LDCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY <br /> ❑3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY 413 <br /> III.TANK OWNER INFORMATION <br /> TANKOWNERNAME 414 PHONE 415 <br /> JOHN TAYLOR 209 944-9951 <br /> MAILING OR STREET ADDRESS 416 <br /> PO BOX 6098 <br /> CITY 417 STATE 418 ZIPCODE 419 <br /> STOCKTON CA 95206 <br /> TANK OWNER TYPE ❑ 1.CORPORATION ❑X 2.INDIVIDUAL ❑ 4.LOCAL AGENCY/DISTRICT 116.STATE AGENCY 420 <br /> ❑ 3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 44-024966 1 Call(916)322-9669 if questions arise 021 <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ❑ 1.SELF-INSURED ❑4.SURETY BOND ❑ 7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM <br /> + ❑2.GUARANTEE ❑ 5.LETTER OF CREDIT ❑ 8.STATE FUND&CFO LETTER ©99.OTHER <br /> ❑3.INSURANCE ❑6.EXEMPTION ❑ 9.STATE FUND&CD 4n <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one box to indicate which address should be used for legal notifications and mailing. ® 1,FACI11TY ❑2.PROPERTY OWNER ❑3.TANK OWNER 4D <br /> Legal notifications and maifing will be senna the tank owner unless box I or 2 is checked. <br /> VII.APPLICANT SIGNATURE <br /> Certification-I certify that the information provided herein is true and accurate to the best ofmy knowledge. <br /> SIGNATURE OF APPLICANT DATE 424 I PHONE 425 <br /> NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 427 <br /> STATE UST FACHATY NUMBER(For wlvc way) 42s 1998 UPGRADE CERTIFICATE NUMBER(Fwscn mcomy) 4M <br /> Is 1998 Compliant?Y <br /> UPCF(1/99 revised) �, <br />