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'IFIED PROGRAM CONSOLIDATED FORM - PR p:PR052421 FAC M:FA00 Sul UNDERGROUND STORAGE TANKS - FACILITY 1I3�B7 (one page per site) TYPE OF ACTION ❑ I.NEW SITE PERMIT ❑ 3.RENEWAL PERMIT 5.CHANGE OF MFORMATION ❑ 7.PERMANENTLYC ED SITE (Check one item only) ❑ 4.AMENDED PERMIT rpreiN cban8a Mxal "duty [:] 8.TANK REMO ❑6.'ILMPORARI 5111 CLOSURE 400 I.FACILITY/SITE INFORMATION 619 CENTRAL AVE.TRACY BUSINESS NAMEIssme as FACILITY NAME cx DBA-Wing Bosasse As) 3 FACILITY IDIPRIDI TRACY CITY OF FA0016254 PR0524210 NEAREST CROSS STREET FACILITY OWNER TYPE ❑ 4.LOCAL AGENCY/DISTRICT- 401 ® I.CORPORATION ❑ 5.COUNTY AGENCY- BUSINESS ❑2.INDIVIDUAL® I.GAS STATION ❑ 3.FARM ❑ 5.COMMERCIAL ❑ 6.STATE AGENCY' TYPE ❑ 2.DISTRIBUTOR ❑4.PROCESSOR ❑6.OTHER 403 ❑ 3.PARTNERSHIPEl 7. 402 FEDERAL AGENCY' TOTAL NUMBER OF TANKS Is facility on Indian Reservation or 9f owner of UST is a public agency:name ofsupervisor of division,section or office which operates REMAINING AT SITE trusllands? the UST(This is the contact Person for the tank records.) 404 ❑ Yes ® No 405 406 11.PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407 PHONE 408 MAILING OR STREET ADDRESS 409 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 CITY 411 1 STATE 418 ZIP CODE 419 TANK OWNER TYPE ❑ 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- 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 ❑3.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. ❑ I FACILITY (K 2.PROPERTY OWNER ❑3.TANK OWNER 423 Legal notifications and mailing will be sent to the tmdc owner unless box I or 2 is checked. VII-APPLICANT SIGNATURE Certification-I certify that the information provided herein is we and accurate to the best of my knowledge. SIGNATURE OF APPLICANT DATE 424 PHONE 425 NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 431 STATE UST FACILITY NUMBER(Fv kul avady) 428 1998 UPGRADE CERTIFICATE NUNIBER(Fv local aeeany) 429 Is 1998 Compliant? UPCF(1/99 revised)