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IFIED PROGRAM CONSOLIDATED FORK "I PR#:PRO5065M `tom FAC#:FAOW7486 f/ UNDERGROUND STORAGE TANKS -FACIL OI I f I (q (one page per site G1 f` TYPE OF ACTION ❑ 1.NEW SITE PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.C11:A,AG1.0i FONS1A110N ❑ 7.PERMANENTLYCL0SED SITE rb� (Check one item only) ❑ 4."ENDED PERMIT sp o,dunce l«at me Duty___ - ❑ e.TANK REMOVED ❑ 1, t AIP0R ARV SITI_CL04 M k00 L FACILITY/SITE INFORMATION 1789 W CHARTER WAY.STOCKTON BUSINESS NAME(Same ae FACILITY NAME or DBA-Dong Bmmrss A4) g FACILITY ID# PR H1# COUNTRY MARKETPLACE FA0007486 PRO506538 NEAREST CROSS STREET FACILITY OWNER TYPE ❑ 4.LOCAL AGENCI(MISTRICT' 401 E] 1.CORPORATION CHARTER WY ❑ 5.COUNTY AGENCY' BUSINESS ❑ 1.GAS STATION ❑ 3.FARM ❑ 5.COMMERCIAL ❑ 2.INDIVIDUAL [1 6.STATE AGENCY' TYPE [:1 3.PARTNERSHIP 402 ❑ 2.DISTRBUTOR E] 4.PROCESSOR E] 6.OTHER IOJ El ].FEDERAL AGENCY' TOTAL NUMBER OF TANKS Is facility on Indian Reservation or 'Ifowner ofUST is a public agency:name ofsupervisor ofdivision,seems or office which operates REMAINING AT SITE trustlands? the UST(This is the contact person for the tank records.) 4a ❑ Yes 99 No 405 GILL,SUKH&KAMAL 406 II.PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407PHONE 409 209 550-0621 MARLING OR STREET ADDRESS 409 621 NINTH ST CITY 410 STATE ,,, ZIP CODE 412 MODESTO CA 95354 PROPERTY OWNER TYPE ❑ I CORPORATION ❑ 2.INDIVIDUAL ❑ 4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY ❑3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY 415 III.TANK OWNER INFORMATION TANKOWNERNAME 414 PHONE 415 RANIUO MARK 209 870-3508 MAILING OR STREET ADDRESS 416 621 NINTH ST CITY 417 STATE g zIP CODE 9 MODESTO CA 95354 TANK OWNER TYPE ❑ L 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- 744041095 1 Call(916)322-9669 if questions arise 431 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 0 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 far legal notifications and mailing. M 1.FACILITY ❑2.PROPERTY OWNER ❑ 3.TANK OWNER 4D Legal notifications and mailing will be sent to the tank owner unless box 1 or 2 is checked. VII.APPLICANT SIGNATURE Cenificafion-1 certify that the information provided herein is true and accurate to the ben cfmy knowledge. SIGNATURE OF APPLICANT DATE 424 1 PHONE 425 (209) 870-3508 NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 427 RANIUO,MARK OWNER STATE UST FACILITY NUMBER(Faua..,ov, 423 1998 UPGRADE CERTIFICATE NUMBER(For local Dee only) 429 Is 1998 Compliant?Y UPCF(1/99 revised)