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Jan 22 03 06: 45p RrillkRob a <br /> '2'1 rtson 2092-3176 P. 3 <br /> nliLtlirnn.i 11: /nf :39 FIFTH FI OOR PAGE M <br /> UNIFIED PROGRAM CONsOILIDAT'ED.FORM / �a Ilk a:Pao272519 <br /> y�, (� O <br /> r�-` •] FAC W:FAOpppytl3 <br /> UNDERGROUND STORA QU TANKS-rACIL X <br /> x/31 job <br /> (One page prr cite? <br /> TYPE <br /> OF one im only) <br /> [1 i.Nyw StTF PiftylT ❑3 R DED PWALPEERMrr ❑ S.CIIANGL OFW FORMATION 7.Pvzm N%N'rj v Moser)s E <br /> (Cb: mi <br /> Gkanciemand 4.AM y <br /> ❑C TANK fMMOvro <br /> oexu�a "R <br /> - _ IJ 6.TEMPtlttARY,tTF C605UttE «uu <br /> I,FACILITY/SITE INFOIIMAT)ON 233 rywTOR[ibg.LC�nI <br /> AUSTRESSNA4IE(S,-c,trPAQLttrNAmL,rDDA,pgyy3�,,,ngrAs) t'h<:1L17 PRIDh '- <br /> IARLST LRI'S SSR76w FA()a0048.1 IrRO;32519 - <br /> ,kLARi-57'CROSS STREET •�� ��� fAGi117'Y OW415x TYPE <br /> VICT'UR d8' p 1.CORPORA„ON d LOCAL A(�NCY/O13TlUtr• <br /> Bu$INESS I.GA55'iArron ❑S•C0(JNTYAr,ENCY• <br /> TYPE ® a 3 FARu ❑,.cOMMER0 L ❑2.1NrnvcouAL [r7 a,STATE Arl Nr,v- <br /> ❑2.0(STFtusuroa 4•PROCLSS()R a.orrrPR ioI ❑3,PARTI`ERSFtIp .os <br /> l�I •, <br /> 1: CnERAL ACENCv- <br /> 70TAL\IU'111 FR OF TAN1�j (S lbcility an,ljsdtan)tridM1dhrm or - <br /> AEMA(N7NG AT SITS vusdAnOS” •Ilowaet dfUST is a ppblie fptnGy:name er euDcrviaor erai«ixtan.secrtvn or OCCc wniU arlMtto <br /> urc OST(This it the omut pawn rat die rank tctortlS•) <br /> rc+ Y`6 ❑` Na .as HEINZ,DALE 209-948.9412 'a <br /> fI.1?AOPERTY OWNER TNFORMATION <br /> PRUPEItI'Y OMER NAMLt ,�I PHONS <br /> K'�fOX ENTERPRISES ioe <br /> MAILf�Iu Ott�7 >r_ADDUSS — 204 367.7516 <br /> 233 E EAST VICTOR RD +°' <br /> C'17Y ,tp SAAIG ,II LIPCUDr ��, <br /> LODI CA 9tiL40 <br /> PRUPL•'RTY OWNER TY? -- , <br /> 187 I COKYOKATIOr` O 2.iNDIvIDUAL ©4.LOCAL.ACM..NCY I DISTRICT ❑4.STATE AGENCY <br /> ❑3.PARTNERSI♦IP Cl s.COLNTY AGENCY 7 MX-AN,AGENCY atr <br /> 11I.TANK OWNER INFOPUNIATION <br /> 77mx ERNAMI; <br /> WOOLSEYOIL 14 PHONE .10 <br /> INC.C (209 948-9422 <br /> MAIL)NCORSIMEI AUQItLSs <br /> lab FRANK WE5'FCIR <br /> u4 <br /> CITY 417 S7'Alt „= ZIPCl7QL <br /> STOCKTON' CA 95206 <br /> Ta'n.K vwNrx TYPEI.CORPORATION ❑2.nlMrVmUA.L CI 4.LOCAL AtrE;NCY t DISTkICT Cl S.5TATE AcrNcY Qu <br /> 3.1rAR-mummp u J.COUNTY AGYNCY ❑7,F DERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NVM8FR <br /> 7Y(TK.)HQ 44 44-037688 _ ., -.. Call(9I6)322-9669 if questions arise <br /> V.PETROLFAIM VST VINANCIAL RESPONSIBILCI'1 <br /> INDICATE&ILTHOD(a) U I.SELF.rN.;I RFD L I 4.5 <br /> UItL•TY 80NM •� ?.STATL•tlz'ND ❑ 10.LOCAL GOVT tvtEClIANJSbf <br /> ❑2.GUARAw-ru L S.LETTER OF CRLDlT © B.STATE 1`0N0 A CI:O r.ETTER 1]99.OTHER <br /> I-7 J 1NSU3RANCT: ❑6.LXEMMON © 9.STA'fL•l''UVU&CU 4:3 <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check ons;box to inJl�,�,.hich addrpep enaald tc ua�Tui tey,l oocirycaranb and ttlaiWlg. ' <br /> 1.FACILITY -)2.PROPERTY OWNER ❑3.TANK OWNER 423 <br /> 1.4341 norificft'W$Ud fwdgng»11 he rent co the senle own"unkss Lor;I e,?u sheeked. <br /> V11,APPLICANT SIG ATURE - <br /> Cpii 34 -1 to Ty A41 t%l inforrtmrimt pto.ded hcein to uoc and accarwt in die bcS,of my Wwleag,. <br /> S10NA7S. AT I T UA'i az. <br /> 7Pof <br /> P/� 1�3 - r <br /> N or Afi'iJCANi(prior) ,,26OF/APPl.li;A, r <br /> 427 <br /> r 1 C' f/r'-Fre= (/( '—�h�/,be�7Jr ���?9"lL �i� Tf•✓� <br /> STATE UST FAC1LfTY NIJMDLR(Yor bc.I.4miyl air 'ly9$U]'(T�,{p,G CEk'1I1`IGASE VUMAFA(snrar�r•dc,.a.l rzv <br /> TS)998 comyltantT Y <br /> LIPCF( visr <br />