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-1NIFIED PROGRAM CONSOLIDATED FORT PR#:PR0231511 Nft# ��je7rpl p#:FA000 UNDERGROUND STORAGE TANKS -FAC ITY 2v 5 U�J (one page per site) A2 TYPE OF ACTION ❑ 1.NEW SITE PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENTLY CLOSED SITE (Check one item only) ❑ 4,AMENDED PERMIT ❑ 8.TANK REMOVED 6.TEMPORARY SITE CLOSURE 400 1.FACILITY/SITE INFORMATION 7611 S AIRPORT WAY,STOCKTON BUSINESS NAME(9wen FACaHYN ceDBA-Doing Burner As) 9 FACILITY ID# PR m# FA0003695 PRO231511 1 NEAREST CROSS STREET FACILITY OWNER TYPE El001 4.LOCAL AGENCY/DISTRICT- AIRPORT WAY A 1.CORPORATION El 5.COUNTY AGENCY- BUSINESS ❑ 1.GAS STATION E]3.FARM ® 5.COMMERCIAL ❑ 2.INDIVIDUAL ❑ 6.STATE AGENCY- TYPE ❑ 2.DISTRIBUTOR ❑4.PROCESSOR ❑ 6.OTHER 4a3 ❑ 3.PARTNERSHIP ❑ 7.FEDERAL AGENCY' 402 TOTAL NUMBER OF TANKS Is facility on Indian Reservation or *Yawner of UST is a public agency:name ofmPrMiS0T of division,section or office which operates REMAINING Al SITE tros0ands? the UST(This is the contact person for the tank records.) l 404 ❑ Yes ®No 405 abs 11.PROPERTY OWNER INFORMATION ah PROPERTY OWNER NAME ( 4po PHONE c �r�c,�L��` La . (fir MAILING OR STREET ADDRESS ^ /) j /1 -�M c '/ 1^ 'y 409 "Cxa-oaoxrc2=r`a:c •L l 1(,j IL �, - �J'i PG 6 CITY ^ 410 STATE ZIP CODE ,Fz 412 V7�ac VER r e�A irk- CA 411 e3-15�a PROPERTY OWNER TYPE ® 1.CORPORATION ❑ 2.INDIVIDUAL ❑ 4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY ❑3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY 413 I11.TANK OWNER INFORMATION TANK OWNER NAME 414 PHONE 415 MAILING OR STREET ADDRESS 416 +0410*#5t5" CITY 417 STATE 411 1 ZIP CODE 419 1V.&NCQLU4LR+ I -;W-Pr- 996444S44- 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- 44-011765 1 Call(916)322-9669 if questions arise 421 V.PETROLEUM UST FINANCIAL RESPONSIBILITY INDICATE METHOD(s) -01 SELF-INSURED ❑4.SURETY BOND ❑ 7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM ❑2.GUARANTEE ❑5.LETTER OF CREDIT 'off.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,FACI.ITY ❑ 2.PROPERTY OWNER E3 3.TANK OWNER 423 Legal notifications and mailing will he sent to the tank owner unless box 1 or 2 is checked. VII.APPLICANT SIGNATURE Certification-I certify that the infomution provided herein is true and accurate to the best ofmy knowledge. SIGNATURE OF APPLICANT DATE 424 PHONE 425 NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 422 STATE UST FACILITY NUMBER(Fnlodl or only) 428 1998 UPGRADE CERTIFICATE NUMBER(F-kaki--b) 429 Is 1998 Compliant?Y UPCF(1/99 revised)