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May :i? OG 04: 03p F'. 2
<br /> UNIFIED PJl1OGRAM CCS MATED FORM DI
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<br /> UNDERGROUND STORAGE TANKS- FACILITY W, It OL
<br /> 'TYPE Or AC'!'!ON q I.Naw rlixmn, 0 3.PXNE a'AI,1Ii-'RMrr wro.
<br /> j (Chx(ic om a:ear xily) Cl❑5.CFIANCIL'OF ❑7.Pl:it�f.9_�IvT..('U)SFEI SI'iF
<br /> 17 A1�SJ 1>3in PBRMl1'(Slxcify elWagrp} _ _ re S.TANS IdtMt)VED
<br /> (]6.V01URARY SI1't>CI,(}TLME
<br /> _ L FACILI'TY/SITE INFORMATION
<br /> HUSINI:SSN/,MI c�wa<nx>n(uJnwnlvr; pl>+ r�,;neJsu�emti�) 3. FACfI.rrY
<br /> Vest Malley Ala Sof u
<br /> '.vi;ARESTCR(MFSTREk:f ,Olr rACII,rIYOwNF:R'IYFEi 4.1ACALf(C*FNC'Y/DIST.RIC'i'
<br /> Na + ( I.CORPORATION "]5.C01)N'l-Y A07VNCY"
<br /> 13L15TIY:Sti 1.(T,sI'FITiON 3.i'ARM��5.COMMERCIAL p3`I []2.INDMDL'AL, ]6.S't'ATi;A0 NCY-
<br /> 'rYPF 0 2.Dib"I'/(IU17TOR El 6•,PROCESSOR []6.O'IIIER I ©3.PARl"NFRSHIP 7,1`ED13ItA;.AM-NC:Y"
<br /> TC)TALNUMPF-M CIF TA,IKS a;,. Is fatciliy on Indian Rcsrn•stion All "if orates of(Ar is u public apmey nacre at suj,ery;r of•Jivisi«. cg;or�'a16:
<br /> REMAINI 40 A'r.3I T, os tmK lands? othce wh ch x rca tpc t S'1'.('llt r is L`e ntaa prt�on£x LSC Lm c r,axle
<br /> 3 u Yos 0 Na Leo Lugo
<br /> 11, PROPERTY OWNER INFORMATION
<br /> PROMR-1YOWN'EI;
<br /> Bodrock Oil 925 TX),(j9W
<br /> MAMD10 OK%TI':EFT',WORFSS
<br /> P.O.Box 1245
<br /> CITY
<br /> LIPC7:;DE <lz
<br /> San Ramon _h CA 4 94583 _
<br /> Pb:UPF;R7•Y 01tlN;w"TYPE 1..CORPORA710N M.NDIVIDUAL 4.L0CAl,AGkNCY l D3S!R:(,'T
<br /> M 0 1 PAR•1NUSIlIP ❑5.COl3N'I'Y AOENC't �[a 7_'-FDEiZAl.AG11Nl,,y
<br /> ILL TANK O'*-NEE INFORMATION
<br /> TAN),cOWNER NiU:�,' � 414.
<br /> Balmck Oil J25925
<br /> ��C.0000
<br /> M_t UNQ OR 5TRE T dV3DRF,83 - 41e.
<br /> P.O.Box 1245 ---
<br /> CITY 41'. z rATE 41x.I zlp coDF, 119.
<br /> st:amo� CA 94583
<br /> 7'AD;K01�fiJy<'iS'PB Q�1.CORFY)R_X5_dN 2.1*IJAvIDUAL 4.LOCAL A(iXNCY/Dl&TP.CC r <.S`FA7E AGF,NCY 411
<br /> _ U 3.PARTNERSIMP []5.COUNTY AGE,CY ©7.FEDERA],AGEN:CY
<br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER ^--
<br /> TY(nQ HQ 44 U 4 Call(936)322-9669 if quesbons arise
<br /> V.PETROLEUM UST FINANCIAL RESPONSE3111 Y
<br /> INAIC--ATE�IE'CFIOL7{s} CI
<br /> I.,6LF•IIq.UX1 1? 04 SUR!{'C Y BOIQD ❑i.STATti 1l;Nfp 0 IC.MXW.GOVT AAI:('1 V0:J 31x1 12Z.
<br /> Cl Z Otletlt/u�'!'13S ❑S LEi icR 0:'(-.KU'UT STAT3. Tm:x3
<br /> ❑3 luS1 RtAI iC1; Q 6.mo.,MPTION 9.STA1'li 1•l ND&CD -
<br /> VL LEGAL NOTIFICATION AND MAILING ADDREIP+i
<br /> Clwcl;urK box to in4ic,t: vhlch sdd: be t ml ir1 legalooliiW A omaid MQIor
<br /> 1.r�41 notif+:at+xc and m3iuruy,,.-]11 bo NNA::,the'ank cntfor chess b=t of 7%s Cdxkod [3 1,rAcit,l7 Y 02. ?RQPF:RTY CWIa KK
<br /> _ VIL APPLICANT SIGNATURE
<br /> Certificatiar, i atf=fy drat tln tntoras:xirf,provided hc�eic is true sod a<r�teute to tIu bustoFmy i(nowl:3gc _ ��
<br /> SIGNAI'IIREOF-•Aff'-,C. RATE s 1,014B .143
<br /> 5/8106 ' 510.385.3039
<br /> NAME OY APPIJCV4I-(Taint) 5 � ^as. TI'1'Lli OF APPLICANT
<br /> Trac ,DtIIBdak CJC71t;Y'8t Nlailctlga
<br /> STA.I'li tlST'FA,
<br /> IL Il Y tiL R1IiF:R(�;a�y�� ;; 399817AjRADE CERTIFICATE NU ABER rAj.,,xy
<br /> ';�9}ata ElculotlL I.AauVC.
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