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IFIED PROGRAM CONSOLIDATED FOR114 p PR#:PR0231728 F C#:FAO 103 UNDERGROUND STORAGE TANKS -FACI T � �\ (one page per site) OF ACTION ❑ I.NEW SITE PERMIT ❑ 3.RENEWAL PERMITS CHANGE OF INFORMATION ❑ 7.PERMANENTLY CLO SITE eck one item only) _ ❑ 4,AMENDED PERMIT Vmfy change I«al use mty -18.TALAR REMO 1 V ❑6 TEMPORARY SITE CLOSURE I.FACILITY/SITE INFORMATION 1113 SHAW RD,STOCKTON BUSINESS NAME(Semeat FACILITYNAMBar DBA-Doing BminerAs) FACILITY ID# PR ID# UNIVERSAL SWEEPINGS SERVICES FA0003565 PR0231728 NEAREST CROSS STREET FACILITY OWNER TYPE ❑ 4.LOCAL AGENCY/DIs RICT' 4m ❑ 1.CORPORATION ❑ 5.COUNTY AGENCY' ' BUSINESS ❑ I.GAS STATION ❑ 3.FARM ® 5.COMMERCIAL ❑ 2.INDIVIDUAL ❑ 6.STATE AGENCY' TYPE ❑ 2 DISTRIBUTOR ❑4.PROCESSOR ❑b.OTHER 4a3 3.PARTNERSHIP ❑ 7.FEDERAL AGENCY' 402 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 trusdands? the UST(This is the contact person for the tank records.) 4a4 ❑ Yes (T No 405 406 11.PROPERTY OWNER INFORMATION PROPERTY OWNERNAME 407 PHONE 408 CLl A ,Ja ella - Wy - 3 MAILING OR STREET ADDRESS I 409 PO BOX 28010 CITY 411 1 STATE 411 ZIP CODE 412 SAN JOSE CA 95159 PROPERTY OWNER TYPE ❑ I.CORPORATION ❑ 2.INDIVIDUAL [:14.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY M.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY 412 III.TANK OWNER INFORMATION TANKOWNERNAME 414 PHONE415 UNIVERSAL SWEEPINGS SERVICES lion -C� I - 3 7 MAILING OR STREET ADDRESS 416 PO BOX 28010 zIP CODE CITY 417 STATE 418 419 SAN JOSE CA 95159 TANK OWNER TYPE ❑ L CORPORATION ❑ 2.INDIVIDUAL ❑ 4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENI 7Y 420 Pj.PARTNERSHIP ❑ 5.COUNTY AGENCY 117.FEDERAL AGENCY IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY(TK)HQ 44- 44-024845 1 Call(916)322-9669 if questions arise 631 V.PETROLEUM UST FINANCIAL RESPONSIBILITY INDICATE METHOD(s) ❑ 1.SELF-INSURED 1:14.SURETY BOND ❑ 7.STATE FUND ❑ 10.LOCAL GOVT MENANISM ❑2.GUARANTEE 1:15.LETTER OF CREDIT ❑ 8.STATE FUND&CFO LETTER 0 99.OTHER ❑3.INSURANCE ❑6.EXEMPTION ❑ 9.STATE FUND&CD 4n 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 win be sent to the tank owner unless box 1 or 2 is checked. VIL APPLICANT SIGNATURE Certification-I certify that the infomvtion provided herein is true and accurate to the best of my knowledge. SI OF PLIC DATE 424 PHONE 425 N OF APPLICANT(print) 426 TITLE OF APPLICANT 427 LL a oc"✓NE12- STATE UST FACILITY NIUMBER(For 1.1 cny) 4''s 1998 UPGRADE CERTIFICATE NUMBER(Forl«nl me ouy) 429 Is 1998 Compliant?Y UPCF(1/99 revised)