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NIFIED PROGRAM CONSOLIDATED FOR$ PR#:PR023160C O yQAC#:FA0000957 UNDERGROUND STORAGE TANKS -FACILI l`' a 7163 `' (one page per sit ) TYPE OF ACTION El I.NEW srrE PERMIT E] 3.RENEWAL PERMIT yrn 5.CHANGE OF INFORMATION E] ].PERMANENTLY CLOSED SITE (Check one item only) ❑ 4,AMENDED PERMIT f4 ❑ B.TANK REMOVED ❑6.TEMPORARY SITE CLOSURE 400 I.FACILITY/SITE INFORMATION 14800 5 HWY 99,MANTECA BUSINESSNAME(samrm FACB.ITYNAMERDBA-Doing Bmbns N) s FACILITY ID# PR ID# LATHROP GAS&FOOD MART FA0000957 PR0231600 NEAREST CROSS STREET FACII.ITY OWNER TYPE HWY 99 401 ❑ 1.CORPORATION El 3.LOCAL AGENCY/DISTRICT- ORATION GENCY DISTR CT' � BUSINESS El 5.COUNTY AGENCY- BUSINESS 1.GAS STATION ❑3.FARM ❑ 5.COMMERCIAL 2.INDIVIDUAL ❑ 6.STATE AGENCY" ❑2.DISTRIBUTOR ❑4.PROCESSOR ❑ 6.OTHER 403 ❑ 3.PARTNERSHIP ❑ 402].FEDERAL AGENCY" REMAINING AT SIT'E TAL NUMBER OF MAINITANRS kfaclLtyon Indian Reservation or *1fowaer of UST is a public agency:name ofsupervisor ofdivision,section or office which operates 3 tnlstlands? the UST(This is the contact person for the took records.) 404 ❑ Yes ® No 405 406 II.PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 4m PHONE Y65_31f2j Ons C L SSD L. 209 .5,221 466 MARLING ORS ET ADORE PO BOX 1207 409 CITY 010 STATE 411 ZIP CODE 412 STOCKTON I CA 95201 PROPERTY OWNER TYPE ® 1.CORPORATION ❑ 2.INDIVIDUAL ❑ 4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY 1:13.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY 413 III.TANK OWNER INFORMATION 830` / Q TANK OWNER NAME r I4 1 /1 \1 /♦{ ,4Fr/_� {1+� PHONE 10 0 �A 1 ,V Jif� 1 •�/ 1 1' 1 60 41, 415 MAILING OR STREET ADDRESS 209 466-"2'r fA�7 1225 PA lbrg4f' Dr' . 416 CITY 419 STATE 418 ZIP CODE 419 oT QK-T-Q4r � A(� CA 13r 9I J) �ai� S[S l•Ji� TANK OWNER TYPE -WL COAPORATION2.INDIVIDUAL El4.LOCAL AGENCY/DISTRICT El6.STATE AGENCY 420 3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY(TK)HQ 44- 44-024781 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 CrOVT MECHANISM ❑2.GUARANTEE ❑5.LETTER OF CREDIT ❑ 8.STATE FUND&CFO LETTER MJ99.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.FACIIIT'Y ❑2.PROPERTY OWNER El 3.TANK OWNER 423 Legal notifications and mailing will be sent to the tank owner unless box 1 or 2 is checked. VII.APPLICANT SIGNATURE Certification.I certify that the information 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 027 STATE UST FACILITY NUMBER(Ferkanuc9my) 428 1998 UPGRADE CERTIFICATE NUMBER(Fm19cJmewdy) 429 Is 1998 Compliant?Y UPCF(1/99 revised)