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F) D 0A tl -ty-G2 D PROGRAM CONSOLIDATED FORM PR#:PR0231547 ��I I�3 f D FAC#:FA0003848 UNDERGROUND STORAGE TANKS -FACILITY (one page per site) TYPE OF ACTION ❑ L NEW SITE PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENTLY CLOSED SITE (Check one item only) ;K4.AMENDED PERMIT ❑ 8.TANK REMOVED ❑6.TEMPORARY SITE CLOSURE 400 I.FACILITY/SITE INFORMATION 13850 N DE VRIES RD,LODI FACILITY ID# PR ID# BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) g WORLDCOM FA0003848 PR0231547 1 NEAREST CROSS STREET FACILITY OWNER TYPE ❑ 4.LOCAL AGENCY/DISTRICT* DEVRIES 401 �&I.CORPORATION ❑ S.COUNTY AGENCY* BUSINESS [!g 1.GAS STATION ❑ 3.FARM ❑ 5.COMMERCIAL ❑ 2.INDIVIDUAL ❑ 6.STATE AGENCY* TYPE [:] E] E] E] 3.PARTNERSHIP E] 402 2.DISTRIBUTOR 4.PROCESSOR 6.OTHER 403 7.FEDERAL AGENCY* 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 REMAINING AT SITE trustlands? the UST(This is the contact person for the tank records.) 404 ❑ Yes ® No 405 Le w'%5 �� a 406 II.PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407PHONE 408 �s1Jcz' -'l 1W- Is I MAILING OR STREET ADDRESS 409 ani v N, 4% t CITY 410 STATE 411 ZIP CODE _ 412 PROPERTY OWNER TYPE ® 1 CORPORATION ❑ 2.INDIVIDUAL ❑ 4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY ❑3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY 413 III.TANK OWNER INFORMATION TANK OWNER NAME 414 PHONE 415 MAILING OR STREET ADDRESS 416 lH uzl (; I "Ile Or CITY i 417 STATE �7' 418 ZIP CODE rR V 419 TANK OWNER TYPE L CORPORATION ❑ 2.INDIVIDUAL ❑ 4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY 420 ❑ 3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY(TK)HQ 44- 44-024750 I Call(916)322-9669 if questions arise 421 V.PETROLEUM UST FINANCIAL RESPONSIBILITY INDICATE METHOD(s) ❑ 1.SELF-INSURED ❑4.SURETY BOND ❑ 7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM ❑2.GUARANTEE ❑ 5.LETTER OF CREDIT ❑ 8.STATE FUND&CFO LETTER ❑X 99.OTHER Jam.INSURANCE ❑6.EXEMPTION ❑ 9.STATE FUND&CD 422 VI.LEGAL NOTIFICATION AND MAILING ADDRESS Check one box to indicate which address should be used for legal notifications and mailing. 1.FACILITY ❑2.PROPERTY OWNER X3.TANK OWNER 423 Legal notifications and mailing will be sent to the tank owner unless box 1 or 2 is checked. VII.APPLICANT SIGNATURE Certification-I certify that the information provided herein is true and accurate to the best of my knowledge. SIGNATURE OF APPLICANT DATE 424 PHONE 425 NAME OF APPLICANT(print) , 1 426 TITLE OF APPLICANT 427 'S �J(' t✓ Rte" (�.wv;fsnn.<n}ttl �tc,w, -ek et STATE UST FACILITY NUMBER(For local ue only) 428 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 Is 1998 Compliant?Y UPCF(1/99 revised)