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0 IFIED PROGRAM CONSOLIDATED FORK' PR #: PR0231014 <br />FAC #: FA0003777 <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 specify chanb e local sue on) Y ❑ 8. TANK REMOVED <br />❑ 6. TEMPORARY SITE CLOSURE 400 <br />I. FACILITY / SITE INFORMATION 1624 ARMY CT. STOCKTON <br />BUSINESS NAME(same as FACILITY NAME or DBA - Doing Business As) ; <br />FACILITY ID# <br />PR ID# <br />) <br />TOYS R US <br />FA0003777 <br />PR0231014 <br />NEAREST CROSS STREET <br />FACILITY OWNER TYPE ❑ 4. LOCAL AGENCY/DISTRICT- <br />ARMY 401® <br />I. CORPORATION ❑ 5. COUNTY AGENCY* <br />❑ 2. INDIVIDUAL ❑ 6. STATE AGENCY - <br />BUSINESS ❑ I. GAS STATION ❑ 3. FARM ❑ 5. COMMERCIAL <br />TYPE <br />❑ 2. DISTRIBUTOR ❑ 4. PROCESSOR A`6.OTHER 407 <br />. ❑ 3PARTNERSHIP 402 <br />❑ 7. FEDERAL AGENCY* <br />TOTAL NUMBER OF TANKS <br />Is facility on Indian Reservation or <br />*Ifowner of UST is a public agency: name of supervisor of division, section or office which operates <br />REMAR41NG AT SITE <br />trustlands? <br />the UST (This is the contact person for the tank records.) <br />404 <br />❑ Yes ® No 405 <br />TOYS R US 406 <br />11. PROPERTY OWNER INFORMATION <br />PROP TYO R E 407 <br />PHONE 408 <br />r <br />209 951-5628 <br />MAILING OR STREET ADDRERS 409 <br />1 pf�: <br />CITY 410 <br />N <br />[STATE 411 <br />ZIP CODE -7 412 <br />SGL -IN A <br />-EPA- <br />PROPERTY OWNER TYPE ®l. CORPORATION ❑ 2. INDIVIDUAL ❑ 4. LOCAL AGENCY / DISTRICT ❑ 6. STATE AGENCY <br />E13. PARTNERSHIP ❑ 5. COUNTY AGENCY ❑ 7. FEDERAL AGENCY 413 <br />III. TANK OWNER INFORMATION <br />TANK OWNER NAME 414 <br />PHONE 415 <br />TOYS R US <br />(209) 951-5628 <br />MAILING OR STREET ADDRESS 416 <br />1575 CASE ST <br />CITY 417 <br />STATE 411 <br />ZIP CODE 419 <br />ORANGE <br />CA <br />92867-3635 <br />TANK OWNER TYPE ® 1. CORPORATION ❑ 2. INDIVIDUAL ❑ 4. LOCAL AGENCY/ DISTRICT ❑ 6. STATE AGENCY 420 <br />❑ 3. PARTNERSHIP 1:15. COUNTY AGENCY ❑ 7. FEDERAL AGENCY <br />TANK OPERATOR INFORMATION <br />TANK OPERATOR NAMEf TANK OPERATOR TITLE <br />l e � � A �,� MANAGER <br />IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br />TY (TK) HQ 44- <br />44-024490 <br />1 Call (916) 322-9669 if questions arise 4'1 <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 JR99.OTHER <br />19'3. 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. X 1, FACILITY ❑ 2. PROPERTY OWNER ❑ 3. TANK OWNER +' <br />LJ <br />Legal notifications and mailing will be sent to the tank owner unless box I or 2 is checked. <br />VII. APPLICANT SIGNATURE <br />Certification - I certify that the information provided herein is true and accurate to the best of my knowledge. <br />SIGNATURE OF APPLICANT <br />DATE 424 <br />PHONE 411 <br />NAME OF APPLICANT (print) 426 <br />TITLE OF APPLICANT 41 <br />STATE UST FACILITY NUMBER (For low ue only) 428 <br />1998 UPGRADE CERTIFICATE NUMBER (For local uu only) 429 <br />Is 1998 Compliant' Y <br />UPCF (1/99 revised) <br />