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1 11 <br />FIED PROGRAM CONSOLIDATED FORMIS 1 PR #: PR0231405 <br />0 <br />60 (o FAC #: FA0003164 <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 change local we only ❑ 8. TANK REMOVED <br />❑ 6. 1 LMPORARY 5111: CLOSURE. 400 <br />1. FACILITY / SITE INFORMATION 574 W GRANT LINE RD, TRACY <br />BUSINESS NAME (Same as FACILITY NAME or DBA - Doing Business As) 3 <br />FACILITY <br />PR ID # <br />TRACY GET N GO MART <br />,1D# <br />FA0003164 <br />PR0231405 Tj <br />1 <br />NEAREST CROSS STREET <br />FACILITY OWNER TYPE <br />El 4. LOCAL AGENCY/DISTRtCT' <br />GRANTLINE aoI <br />❑ 1. CORPORATION <br />❑ 5. COUNTY AGENCY - <br />❑ 2. INDIVIDUAL <br />❑ 6. STATE AGENCY' <br />BUSINESS �/ <br />1. GAS STATION ❑ 3. FARM 5. COMMERCIAL <br />TYPE <br />❑ 2. DISTRIBUTOR ❑ 4. PROCESSOR ❑ 6. OTHER 403 <br />>r3. PARTNERSHIP ❑ 7. FEDERAL AGENCY' 402 <br />TOTAL NUMBER OF TANKS <br />Is facility on Indian Reservation or <br />"If owner of UST is a public agency: name of supervisor of division, section or office which operates <br />REMAINING AT SITE <br />trustlands? <br />the UST (This is the contact person for the tank records.) <br />14- 404 <br />❑ Yes ® No 405 <br />406 <br />Il. PROPERTY OWNER INFORMATION <br />PROPERTY O R NAME 407 <br />PHONE 409 <br />209 833-3416 <br />MAILING OR ST ADD SS 409 <br />574 W GRANTLINE <br />CITY 410 <br />STATE 411 <br />ZIP CODE 412 <br />TRACY <br />I CA <br />95376 <br />PROPERTY OWNER TYPE 1. CORPORATION ❑ 2. INDIVIDUAL ❑ 4. LOCAL AGENCY / DISTRICT ❑ 6. STATE AGENCY <br />PARTNERSHIP ❑ 5. COUNTY AGENCY ❑ 7. FEDERAL AGENCY 413 <br />III. TANK OWNER INFORMATION <br />TANK OWNER NAME 41q <br />PHONE als <br />SINGH SATNAM <br />209 833-3416 <br />MAILING OR STREET ADDRESS 416 <br />574 W GRANTLINE <br />CITY 417 <br />STATE 418 <br />ZIP CODE 419 <br />TRACY <br />CA <br />95376 <br />TANK OWNER TYPE 1. CORPORATION ❑ 2. INDIVIDUAL ❑ 4. LOCAL AGENCY / DISTRICT ❑ 6. STATE AGENCY 420 <br />PARTNERSHIP ❑ 5. COUNTY AGENCY ❑ 7. FEDERAL AGENCY <br />IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br />TY (TK) HQ 44- 1 Call (916) 322-9669 if questions arise 421 <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 1:15. LETTER OF CREDIT -0-8. STATE FUND & CFO LETTER A99. OTHER <br />❑ 3. INSURANCE 1:16. 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. ® 1. FACILITY ❑ 2. PROPERTY OWNER ❑ 3. TANK OWNER 423 <br />Legal notifications and mailing will be sent to the tank owner unless box 1 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 APPaXL'N1_1 <br />DATE 424 <br />J/27/0-3 <br />PHONE 425 <br />( 9% x'33 -,3 W4 <br />NAME OF APPLICANT (print) 426 <br />TITLE OF APPLICANT 427 <br />S-A)rA1 0 i,✓Gy <br />&WAIEZ <br />STATE UST FACILITY NUMBER (For local ue only) 428 <br />1998 UPGRADE CERTIFICATE NUMBER (For local use only) 429 <br />Is 1998 Compliant? <br />UPCF (1/99 revised) <br />