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IFIED PROGRAM CONSOLIDATED FORM PR#:PR0506545 FAC#:FA0007491 UNDERGROUND STORAGE TANKS - FACILITY T Y d rm A (one page per site) TYPE OF ACTION ❑ I.NEW SITE PERMIT ❑ 3.RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7.PERMANENTLY CLOSED SITE (Check one item only) ❑4.AMENDED PERMIT spec change ❑ 8.TANK REMOVED ift Chan local use only ❑6.TEMPORARY SITE CLOSL!RE 400 I.FACILITY/SITE INFORMATION 1524 FRESNO AVE,STOCKTON BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 9 FACILITY ID# PR ID# - COUNTRY MARKETPLACE TRUCK WASH FA0007491 PR0506545 71 NEAREST CROSS STREET 401 FACILITY OWNER TYPE ❑ 4.LOCAL AGENCY/DISTRICT• ® 1.CORPORATION ❑ 5.COUNTY AGENCY* BUSINESS ❑ 1 GAS STATION ❑ 3.FARM ❑ 5.COMMERCIAL ❑ 2.INDIVIDUAL TYPE E] ❑ 6.STATE AGENCY* 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 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 405 406 II.PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407 PHONE 40 MARK RANUIO 209 870-3508 MAILING OR STREET ADDRESS 409 1789 W CHARTER WAY CITY 410 STATE 411 ZIP CODE 412 STOCKTON CA 95206 PROPERTY OWNER TYPE ® 1.CORPORATION ❑ 2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY ❑3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY 41 III.TANK OWNER INFORMATION TANK OWNER NAME 414 PHONE 415 MARK RANUIO 209 870-3508 MAILING OR STREET ADDRESS 416 1789 W CHARTER WY CITY 417 STATE 418 ZIP CODE 419 STOCKTON CA 95206 TANK OWNER TYPE ❑X 1.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- 44-038743 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 ❑2.GUARANTEE ❑5.LETTER OF CREDIT ❑ 8.STATE FUND&CFO LETTER ❑99.OTHER 1913.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 Legal notifications and mailing will be sent to the tank owner unless box I 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 }„ NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 427 STATE UST FACILITY NUMBER(For local ue only 429 1 1998 UPGRADE CERTIFICATE NUMBER(For local use only) - Is 1998 Compliant?Y UPCF(1/99 revised)