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IED PROGRAM CONSOLIDATED F013" PR#:PR023176ow 4 <br /> FAC#:FA0002160 <br /> UNDERGROUND STORAGE TANKS -FACILITY <br /> (one page per site) <br /> TYPE OF ACTION ❑ 1.NEW SITE PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENTLY CLOSED SITE <br /> (Check one item only) ❑ 4.AMENDED PERMIT <br /> ❑ 8.TANK REMOVED <br /> ❑6.TEMPORARY SITE CLOSURE 400 <br /> I.FACILITY/SITE INFORMATION 5611 WATERLOO RD,STOCKTON <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) g FACILITY ID# PR ID# <br /> ORLANDO'S BAIT&TACKLE FA0002160 PR0231764 <br /> NEAREST CROSS STREETEe K ❑4.LOCAL AGENCY/DISTRICT* <br /> WATERLOO 401d 1.CORPORATION <br /> /^" ❑ 5.COUNTY AGENCY* <br /> BUSINESS 1.GAS STATION ❑ 3.FARM ❑ 5.COMMERCIAL ❑ 2.INDIVIDUAL ❑ 6.STATE AGENCY* <br /> TYPE <br /> ❑ 2.DISTRIBUTOR ❑ 4.PROCESSOR E] 6.OTHER 403 ❑ 3.PARTNERSHIP ❑ 7.FEDERAL AGENCY* 402 <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 operates <br /> REMAINING AT SITE trustlands? the UST(This is the contact person for the tank records.) <br /> ❑ Yes ® No aosORLANDO, SAM 406 <br /> II.PROPERTY OWNER INFORMATION <br /> E 407 PHONE 408 <br /> 0r 209 931-2942 <br /> MAILING OR STREET ADDRESS <br /> 409 <br /> 9725 OAKWILDE AVE <br /> CITY 410 rTATE ...TIP CODE 412 <br /> STOCKTON CA 95215 <br /> PROPERTY OWNER TYPE ® 1.CORPORATION ❑ 2.INDIVIDUAL ❑ 4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY <br /> ❑3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY 413 <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> ORLANDO SAM B&MARILYN 209 931-2942 <br /> MAILING OR STREET ADDRESS 416 <br /> 9725 OAKWILDE AVE <br /> CITY 417 1 STATE 418 ZIP CODE 419 <br /> STOCKTON CA 95215 <br /> TANK OWNER TYPE ❑9 1.CORPORATION ❑ 2.INDIVIDUAL ❑ 4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY 420 <br /> ❑ 3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 44-025033 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 ❑ 10.LOCAL GOVT MECHANISM <br /> ❑2.GUARANTEE ❑5.LETTER OF CREDIT ❑ 8.STATE FUND&CFO LETTER 19199.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. ® 1.FACILITY ❑2.PROPERTY OWNER ❑3.TANK OWNER 423 <br /> Legal notifications and mailing will be sent to the tank owner unless box I or 2 is checked. <br /> Certification-1 fy the' ion ro ' ed erein is true and accurate to the best of my knowledge. <br /> L TDA i r�/0_�� 424 PHONE azs <br /> NAME OF API,',LICANT(print) ��/�F 426 TITLE OF APPLICANT *-4'z az7 <br /> STATE UST FACILITY NUMBER(For local-only) 428 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 <br /> /�IT(J,� /l--,ILI 6-73 4 i-- Is 1998 Compliant?Y <br /> UPCF(1/99 revised) I$ <br />