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IFIED PROGRAM CONSOLIDATED FORfV PR#:PRO231243 FAC#:FA0004068 UNDERGROUND STORAGE TANKS -FACILITY f/r /0 2 (one page per site)) TYPE OF ACTION ❑ LNEW SITE PERMIT ❑ 3.RENEWAL PERMIT SCHANGE OF INFORMATION (Check one item only) ❑ ❑ ].PERMANENTLY CLOSED SITE ❑ 4.AMENDED PERMIT sl,miry cM1avgalaatuc o�y Y ❑ B.TANK REMOVED ' ❑b.TEMPORARY SITE CLOSURE 400 I.FACILITY/SITE INFORMATION 1145 S SIERRA NEVADA ST STOCKTON BUSINESS NAME FACILITY NAME m DBA-Doing Business Ar' 3 FACILITYID# PR IDN ANGELICA TEXTILE SERVICES FA0004068 PROz31243 NEARESTCROSS STREET 401 FACILITY OWNER TYPE SIERRA NEVADA ❑ I.ITY OWNER PORATION ❑4.LOCAL AGENCY/DISTRICT' BUSINESS M 1 GAS STATION 3.FARM ❑ 2.INDIVIDUAL ❑ S.STATERCOUNTY AGENCY- El AGENCY- TYPE ❑ ❑ 5.COMMERCIAL ❑ 6.STATE AGENCY' ❑ 2.DISTRIBUTOR ❑4.PROCESSOR ❑ b.OTHER 403 ❑ 3.PARTNERSHIP TOTAL NUMBER OFTANKS ❑ 7.FEDERAL AGENCY- Is 4oz on an Indian Reservation or REMAINING AT SITE tnlstlands? *If owner of UST is a public agency:name ofsupervisor of division,section or office which operates the UST(This is the contact person for the tank records.) 40a [:] Yes ® No 405 FRANK WALLACE 406 R.PROPERTY OWNER INFORMATION PROPERTY OWNER NAME ANGELICA WESTERN RENTAL 411 PHONE 408 MA B,IIVG OR STREE7 AD DRESS 209 941-4327 1145S SIERRA NEVADA 400 CITY STOCKTON 411 STATE 411 ZIP CODE CA 412 PROPERTY OWNER TYPE 95205 ❑ 1.CORPORATION El2.INDIVIDUAL 014.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY ❑3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY 413 III.TANK OWNER INFORMATION TANK OWNER NAME ANGELICA WESTERN RENTAL 434 PHONE 415 MAB-ING OR STREET ADDRESS 209 941-4327 1575 asc cS h ce f CITY 416 STATE 93P,&4, I'l ra 4n 411 ZIP CODE l/ CA 4/7� s TANKOWNER TYPE 93627' �125(U7 -a(j35 ❑ 1.CORPORATION ❑2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY 420 ❑3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY W.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY(TK)HQ 44- 44-024600 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. ® 1.FACILITY ❑2.PROPERTY OWNER ❑3.TANK OWNER 423 Legal notifications and mailing will be sent to the tank owner unless box I or 2 is checked. VII.APPLICANT SIGNATURE Certification-I certify that the infonnxdon provided herein is true and accurate to the best ofmy knowledge. SIGNATURE OF APPLICANT DATE azo PHONE ass NAME OF APPLICANT(print) 6 TITLE OF APPLICANT 427 STATE UST FACILITY NUMBER(For local ac ody) aze 1998 UPGRADE CERTIFICATE NUMBER(Fwimisaeody) 420 Is 1998 Compliant?Y UPCF(1/99 revised)