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IFIED PROGRAM CONSOLIDATED FORI PR #: PR0231014 FAC #: FA0003777 UNDERGROUND STORAGE TANKS -FACILITY �P P/a10-7- (one page per site) TYPE OF ACTION ❑ 1. NEW SITE PERMIT ❑ 3. RENEWAL PERMIT ❑ 5. CHANGE OF INFORMATION ❑ 7. PERMANENTLY CLOSED SITE (Check one item only) ❑ 4. AMENDED PERMIT speciry change local use only ❑ 8. TANK REMOVED ❑ 6. 1 FNIPORARY SITE CLOSURE 400 I. FACILITY / SITE INFORMATION 1624 ARMY CT, STOCKTON BUSINESS NAME (Same as FACILITY NAME or DBA - Doing Business As) 3 FACILITY ID# PR ID# TOYS R US FA0003777 PR0231014 I NEAREST CROSS STREET FACILITY OWNER TYPE E]4. LOCAL AGENCY/DISTRICT* ARMY aol [:] 1 CORPORATION ❑ S. COUNTY AGENCY* ❑ 2. INDIVIDUAL ❑ 6. STATE AGENCY* BUSINESS ❑ 1. GAS STATION ❑ 3. FARM ® 5. COMMERCIAL TYPE ❑ 2. DISTRIBUTOR ❑ 4. PROCESSOR ❑ 6.OTHER 403 ❑ 3. PARTNERSHIP ❑ 7. FEDERAL AGENCY* 402 TOTAL NUMBER OF TANKS Is facility on Indian Reservation or *If owner ofUST 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 405TOYS R US 406 II. PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407 PHONE 408 TOYS R US 209 951-5628 MAILING OR STREET ADDRESS 409 395 W PASSAIC ST CITY 4Io STATE 411 ZIP CODE 412 ROCHELLE PARK NJ 07662 PROPERTY OWNER TYPE ® I. 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 TOYS R US 209 951-5628 N R MAILING OR STREET ADDRESS �% �Af v� y y� �1 345--WZ'7�882kte ST 10 2- `" ^�� r `�:• 1 It► N y �i �� 416 CITY 417 STATE 419 ZIP CODE 419 PC()C_HEL+E PARK M 0 n- mAe" NJ ems- D 7 (2 -Tb TANK OWNER TYPE ❑X 1. CORPORATION ❑ 2. INDIVIDUAL 1:14. 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- 44-024490 1 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 1:12. GUARANTEE ❑ 5. LETTER OF CREDIT ❑ 8. STATE FUND & CFO LETTERX❑ 99. OTHER 1:13. 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 ❑ 3. 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 1 PHONE 425 NAME OF APPLICANT (print) 426 TITLE OF APPLICANT 427 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)