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B <br /> JPFIED PROGRAM CONSOLIDATED FO f <br /> TANKS D1 <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (One page per site) Page_of <br /> TYPE OF ACTION [11.NEW PERMIT ❑3.RENEWAL PERMIT ®5.CHANGE OF INFORMATION [17.PERMANENTLY CLOSED SITE 400 <br /> (Check one item only) ❑4.AMENDED PERMIT (Specify change) [:18.TANK REMOVED <br /> ❑6.TEMPORARY SITE CLOSURE . <br /> I. FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3. FACILITY <br /> r I C;arS 6a _ i <br /> ' ID# 1 <br /> NEAREST CROSS STREET 401. FACILITY OWNER TYPE ❑4.LOCAL AGENCY/DISTRICT* 402 <br /> Park Street ❑ I.CORPORATION ❑5.COUNTY AGENCY* <br /> BUSINESS ® I.GAS STATION [13.FARM ❑5.COMMERCIAL 403• [:12.INDIVIDUAL ❑6.STATE AGENCY* <br /> TYPE ❑2.DISTRIBUTOR [14.PROCESSOR ❑6.OTHER ®3.PARTNERSHIP ❑7.FEDERAL AGENCY* <br /> TOTAL NUMBER OF TANKS 404. Is facility on Indian Reservation 405. *If owner of UST is a public agency: name of supervisor of division,section or 406. <br /> REMAINING AT SITE or trust lands? office which operates the UST. (This is the contact person for the tank records.) <br /> 3 ❑Yes ®No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 408. <br /> Wiley Chandler 209-298-7505 <br /> MAILING OR STREET ADDRESS 409, <br /> P.O. Box 507 <br /> CITY 410. 1 STATE 411. ZIP CODE 412. <br /> Stockton CA 95201 <br /> PROPERTY OWNER TYPE MZ1.CORPORATION ❑2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 413. <br /> 43.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> M. TANK OWNER INFORMATION <br /> TANK OWNER NAME 1 414. PHONE 415. <br /> rCl-U01CI L( 209-298-7505 <br /> MAILING OR STREET ADDRESS 416. <br /> P.O. Box 507 <br /> CITY 417. 1 STATE 418. ZIP CODE 419. <br /> Stockton CA 95201. <br /> TANK OWNER TYPE CORPORATION ❑2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT [16.STATE AGENCY 420. <br /> -X 3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> (TK)HQ-4-4-_q I I I I I I Call(916)322-9669 if questions arise 421 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ❑1.SELF-INSURED ❑4.SURETY BOND OF STATE FUND ❑10.LOCAL GOV'T MECHANISM a„_ <br /> ❑2.GUARANTEE ❑5.LETTER OF CREDIT M8.STATE FUND&CFO LETTER El99.OTHER: <br /> El3.INSURANCE ❑6.EXEMPTION 9.STATE FUND&CD <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 I or 2 is checked. ❑ 1.FACILITY ®2. PROPERTY OWNER ❑3.TANK OWNER 423, <br /> VII. APPLICANT SIGNATURE <br /> Certification: 1 certify that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNATURE OF APPLICANT DATE 424. 1 PHONE 425. <br /> Z✓�--�/��-� 4/06/07 209-298-7505 <br /> NAME OF APPLICANT(print) 426. TITLE OF APPLICANT 427. <br /> r ry. thqr'�e / - �f (A 001.=%f a.� Owner <br /> STATE UST FACILITY NUMBER(Agency use only) 428• 1998 UPGRADE CERTIFICATE NUMBER(Agency use only) 429. <br /> (See Data Element 1,above. <br /> UPCF Hwfwrc-a(1/99)-1/2 http://www.unidoes.org Rev.02/16/00 <br />