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NIFIED PROGRAM CONSOLIDATED FORK �22 PR N:PRO231387 <br /> 1�"/ FAC N:FA0002996 <br /> UNDERGROUND STORAGE TANKS - FACILITY W,�:o� ,Q 1B'l <br /> (one page Per site) <br /> TYPE OF ACTION ❑ 1.NEW SITE PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ ].PERMANENTLY CLOSED SITE <br /> (Cheek oneitem only) ❑ 4.AMENDED PERMIT apeedyebwlesil-stly ❑ 8.TANKREMOVED <br /> ❑6.TEMPORARY SITE CLOSURE 400 <br /> 1.FACILITY/SITE INFORMATION 315 E I ITH ST.TRACY <br /> BUSINESS NAME(S.as FACILITY NAME or DBA-Wing Buri.A.) 3 FACILITY ID# PR ID# <br /> TRACY USD-JNT UNION HIGH FA0002996 PR0231387 <br /> NEAREST CROSS STREET ? F, FACILITY OWNER TYPE <br /> L 111 ❑4.LOCAL AGENCY/DISTRICT- <br /> ELEVENTH <br /> GENCY/DIS R CELEVENTH (V <br /> /tE. 4oI ® LCORPORATION ❑ S.COUNTY AGENCY' <br /> BUSINESS ® 1 GAS STATION [13,FARM ❑ 5.COMMERCIAL ❑2.INDIVIDUAL ❑6.STATE AGENCY' <br /> TYPE ❑ 2.DISTRIBUTOR ❑4.PROCESSOR ❑6.OTHER 4n3 ❑ 3.PARTNERSHIPEl ] 402 <br /> .FEDERAL AGENCY' <br /> TOTAL NUMBER OF TANKS Is facility on Indian Reservation or elf owner of UST m a Wblic agency:name of supervisor of division,section or office which operates <br /> REMAINING AT SITE trustlands? the UST(This is the contact person for the tank records.) <br /> ❑ Yes ® No 405 TRACY HIGH SCHOOL 406 <br /> II.PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407PHONE 408 <br /> TRACY UNIFIED SCHOOL DIST 209 863-3246 <br /> MAILING OR STREET ADDRESS Ass <br /> 1975 W LOWELL AVE <br /> CITY 410 STATE 411 ZIP CODE 412 <br /> TRACY I CA 1 95376 <br /> PROPERTY OWNER TYPE ❑ 1.CORPORATION ❑ 2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ® 6.STATE AGENCY <br /> ❑3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY 413 <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 4,4 PHONE 415 <br /> TRACY UNIFIED SCHOOL DIST 209 830-3246 <br /> MAILING OR STREET ADDRESS 416 <br /> 1975 W LOWELL AVE ZIP CODE 4,9 <br /> CITY 411 STATE 418 <br /> TRACY CA 95376 <br /> TANK OWNER TYPE ❑ I CORPORATION ❑ 2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT 0 6.STATE AGENCY 420 <br /> [:13.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ Z FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 44-024675 1 Call(916)322-9669 if questions arise 021 <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 ❑ S.STATE FUND @.CFO LETTER ®99.OTHER <br /> ❑3.INSURANCE ❑6.EXEMPTION ❑ 9.STATE FUND @ CD 4n <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one box w indicate which address should be used for legal notifications and meding. ® L FACILITY ❑2.PROPERTY OWNER [:13.TANK OWNER 423 <br /> Legat naifrations and mailing will be sent to the tmk owner unless box I or 2 is checked <br /> VII.APPLICANT SIGNATURE <br /> C"Ecalion-1 oenify that the information Provided herein is true and accurate to the best of my knowledge- <br /> SIGNATURE OF APPLICANT DATE 424 PHONE 425 <br /> (209)830-3200 <br /> NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 427 <br /> DENISE WAKEFIELD DIRECTOR OF FACILITIES <br /> STATE UST FACILITY NUMBER(Far i eel minty) 428 1998 UPGRADE CERTIFICATE NUMBER(Far teres ase oom 029 <br /> Is 1998 Compliant? <br /> UPCF(1/99 revised) - - <br /> i Deaf <br />