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� Cly <br /> 17WIED PROGRAM CONSOLIDATED FOR <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page per site) Page 1 of 1 <br /> TYPE OF ACTION ❑ 1.NEW SITE PERMIT ❑3.RENEWAL PERMIT ❑S.CHANGEOF INFORMATION ❑ TPERMANENTLY CLOSED SITE <br /> (Check one item only) IN 4.AMENDED PERMIT specify change local use only ❑ 8.TANK REMOVED <br /> ❑&TEMPORARY SITE CLOSURE 400 <br /> I. FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 FACILITY ID# <br /> FLAG CITY CHEVRON ' <br /> NEAREST CROSS STREET 401 FACILITY OWNER TYPE ❑4.LOCAL AGENCY/DISTRICT* <br /> 6421 Capitol Ave/ 14958 N.Thornton Rd. IN 1.CORPORATION 1715.COUNTY AGENCY* <br /> BUSINESS ❑1.GAS STATION [13.FARM ®5. COMMERCIAL ❑ 2.INDIVIDUAL [16.STATE AGENCY* <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR❑6. OTHER 4o3 ❑ 3.PARTNERSHIP ❑7.FEDERAL AGENCY* U)2 <br /> 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 <br /> REMAINING AT SITE t wtlands? operates the UST(This is the contact person for the tank records.) <br /> 4 404 ❑ Yes IN No 405 406 <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 40 PHONE 408 <br /> Bokides Family Limited Partnership 209-334-0975 <br /> MAILING OR STREET ADDRESS 409 <br /> P.O. Box 1411 <br /> CITY 410 STATE 411 ZIP CODE ail <br /> Woodbridge CA 95258 <br /> PROPERTY OWNER TYPE El 1.CORPORATION 2.INDIVIDUAL 4.LOCAL AGENCY/DISTRICT Lj 6.STATE AGENCY <br /> IN 3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY 413 <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> First Investment Flag City, Inc. 209-334-0975 <br /> MAILING OR STREET ADDRESS 416 <br /> 6421 Capitol Avenue <br /> CITY 417 1 STATE 418 ZIP CODE 419 <br /> Lodi CA 95242 <br /> TANK OWNER TYPE 1.CORPORATION 2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT 0 6.STATE AGENCY 420 <br /> [:13.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY K HQ 44- 1 0 1 3 1 6 1 7 1 5 1 3 1 Call 916 322-9669 if questions arise 421 <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ❑ 1.SELF-INSURED ❑4.SURETY BOND ®7.STATE FUND [:110.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 422 <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one box to indicate which address should be used for legal notifications and mailing. <br /> Legal notifications and mailings will be sent to the tank owner unless box 1 or 2 is checked ❑ L FACILITY ❑2. PROPERTY OWNER IK 3.TANK OWNER 42; <br /> VII.APPLICANT SIGNATURE <br /> Certification-I certify that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNATUOF APPLICANT DATE 424 PHONE 4'-5 <br /> it-, 5 e/Zz J 5 209-334-0975 <br /> NAME OP APPLICANT(print) 426 TIT] APPLICANT 427, <br /> Karen Dhingsa Manager <br /> F <br /> UST FACILITY NUMBER(For local use only) 428 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 <br />