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D PROGRAM CONSOLIDATED F n� <br /> v ti q o� TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page per site) Page I of <br /> TYPE OF ACTION ❑ NEW SITE PERMIT ❑3.RENEWAL PERMIT ❑S.CHANGE OF INFORMATION ❑ 7.PERMANENrLY CLOSED SITE <br /> (Check one item only) ❑4.AMENDED PERMIT specify change local use only ❑ 9.TANK REMOVED <br /> [36.TEMPORARY SITE CLOSURE 400 <br /> I. FACIIdTY/ SITE INFORMATION <br /> BUSINESS NAME(S..FACI�II�T,Y3N3AMEor DBA-Doingauslnen An) 3 FACILITYID# <br /> Van De Pol Ente rises-l9lj�Y W.Charter Way <br /> NEAREST CROSS STREET 401 FACILITY OWNER TYPE 4.LOCAL AGENCY/DISTRICT* <br /> W.Charter& S. Stockton ® 1.CORPORATION ❑5.COUNTY AGENCY* <br /> BUSINESS 1.GAS STATION ❑3.FARM 5. COMMERCIAL ❑ 2.INDIVIDUAL ❑6.STATE AGENCY' <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR[16. OTHER 4o3 ❑ 3.PARTNERSHIP ❑7.FEDERAL AGENCY* 402 <br /> TOTAL NUMBER OF TANKS B facility on Indian Reservation or •Howner ofUSf is a public agency:name of supervisor of division,section or once which <br /> REMAINING AT SITE ttustlands? operates the UST(This is the contact person for the tank records.) <br /> 5 404 ❑ Yes ® No 406 aab <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 401 PHONE 408 <br /> NCC Properties 209 466-5086 <br /> MAILING OR STREET ADDRESS 409 <br /> P.O.Box 1528 <br /> CITY 610 1 STATE 411 ZIP CODE 412 <br /> Stockton CA 95201 <br /> PROPERTY OWNER TYPE MIXORPORATION 2.INDIVIDUAL Lj 4.LOCAL AGENCY/DISTRICT U&STATFAGENCY <br /> ❑3.PARTNERSHIP ❑S.COUNTY AGENCY ❑7.FEDERAL AGENCY 413 <br /> M. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414PHONE 415 <br /> Van De Pot Enterprises 209 465-4321 <br /> MAILING OR STREET ADDRESS 416 <br /> 1001 W.Charter Way <br /> CITY 417 STATE 419 ZIP CODE 419 <br /> Stockton CA 95201 <br /> TANK O WNER TYPE 1.CORPORATION ❑2.INDIVIDUAL Lj 4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 420 <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> W. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY TK HQ 44- 1 0 12 1 5 1 C 1 1 421 <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 ❑5.LETTER OF CREDIT W.STATE FUND&CFO LETTER ❑ 99.OTHER: <br /> [13.INSURANCE [16.EXEMPTION ❑9.STATE FUND&CD 4z <br /> VI. LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one box to indicate which address should be used for legal notifications and mailing. <br /> Legal notifications and mailings will be sent to the tank owner unless box 1 or 2 is checked. ❑ L FACILITY ❑2. PROPERTY OWNER ®3.TANK OWNER 423 <br /> VII. APPLICANT SIGNATURE <br /> Certification-1 certify that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGN6FdjtE OF APPLICANT DATE 424 1 PHONE 425 <br /> q65 3K1 <br /> NAME OF APPLICANT(print) 426 TITLE PLICANT 427 <br /> ,a <br /> L.4> /77. Ow bL5-� fr2ewDcalr <br /> STATE UST FACILITY NUMBER(For local we only) .428 1998 UPGRADE CERTIFICATE NUMBER(For loml ne.coly) 429 <br /> UPCF(1/99 revised) 8 Formerly SWRCB Form A <br />