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UNIFIED PROGRAM CONSOLIDATED FORM `Y� \�AR M:IR0231227 <br /> UNDERGROUND STORAGE TANKS -FACILITY <br /> Z Qp�� <br /> (onepogeparsim) 12 7 0� 2UI- <br /> TYPEOFACTION ❑ 1.NEW SITE PERMIT ❑3.RENEWAL PEWIT ❑ S.CHANGEOFINFO[NIATION ❑7.PERMANENTLYCIUSED SITE <br /> (Check on¢item only) ❑4.AMENDED PERMIT ❑ 8.TANK REMOVED <br /> 114 6.TEMPORARYSITECLOSURE 400 <br /> I.FACILITY/SITE INFORMATION 7647 PACIFIC AVE STOCKTON <br /> BUSR4PSS NAME(54m4.+TACg.l3YNAMe«DaA..,imo�wn Ar) 3 PACD-TfY IDN PR IDM 1 <br /> PeEvvr WLIFoRM1A Ease(, , 172 FA0004033 PR0231227 <br /> ARE37'CROSS STREET FACILITY OWNER TYPE ❑4.LOCAL AGENCYMHSTRICT' <br /> PACIFIC 401 ® I.CORPORATION 0 5.COUNTY AGENCY' <br /> BUSINESS ❑ [12.INDIVIDUAL <br /> 1.GAS STATION ❑3.FARM ❑ 5.COMMERCIAL ❑3.PARTNERSHIP ❑6.STATE AGENCY' 40 <br /> TYPE ❑2.DIS PJBUTOR ❑4.P Rl%:PSSOR 6. SIMM 403 ❑7.FEDERAL AGENCY' <br /> TOTAL NUMBER 10L lad Is fecilreynn lndion eservadon or •IfowneroNST i4apubik egmry.nam¢ofsupervisor ofdi.isim,emlion or oRa whkh operates <br /> REMAINING AT SDE IrusdondO Na UST Otis u Ilia oomact peracm for Me ant,recorde.) <br /> 3 04 ❑ Yes ®NO 403 a ob <br /> Ill.PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAMb 407 PHONE 409 <br /> BEST CALIFORNIA GAS LTD (56 2) 0121 -3 581 <br /> MAILING OR STREET ADDRESS 409 <br /> CITY 13116 IMPERIAL HWY ae STATE ,D ZIP CODE 412 <br /> SANTA FE SPRINGS CA OfI <br /> PROPERT OWNER TYPE ® I.CORPORATION ❑ 2.INDIVIDUAL 04.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 414 PHONE us <br /> 6SSTCAL14=0QNlf} GA-S Ltd. C562) g2I-3 Sfl1 <br /> 416 <br /> MAILING UK 31"h I ADDRESS 7 1 <br /> " <br /> 1 116 ZNIPE(ZIA i nD STATE 41e ZIP CODE 419 <br /> CITY CA q®67 Q <br /> SANT-A,-;::P_ <br /> TANK OWNER TYPE ® I.CORPORATION ❑2.INDIVIDUAL [14.LOCAL AGENCY/DISTRICT' ❑6.STATE AGENCY 420 <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY 117.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 44-032073 '1'ECAP• CLO S GZ Call(916)322-9669 if questions arise 031 <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE MEfHOD(s) ❑ 1.SELF-INSURED ❑4.SURETY BOND ❑ 7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM <br /> ❑2.GUARANTEE ❑5.LETTER OF CREDIT ❑ R STATE FUND&CFO LETTER ❑99.OTHER <br /> ®3.INSURANCE ❑6.EXEMPTION ❑ 9.STATE FUND k CD 422 <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Cheek m¢box to indicate which address ehould teamed for legal notifications and mailing. I.FACILITY X2.PROPERTY OWNER 03.TANK OWNER 423 <br /> "gal nonEes ions and mailing will be sent to the link owner umess box 1 or 2 ve chocked. <br /> VII.APPLICANT SIGNATURE <br /> CmiOcetim-1 ceRRy riot dm iofo�melion provided herein is we end eccmme Io me bell ofmY Mnowledl3e. <br /> SIGNATURE OF APPLICANTlr DATE 424 PHONE ,2s <br /> (91 _• <br /> 12-/?01 Ob (S62-)q24-3581 +c3Ro <br /> NAME OF APPLICANT(print) 474 TITLE OF APPLI ANT 427 <br /> el NS r4NA-17ESCU TM 'per''` <br /> STATE UST FACILITY NUMBER ffw low w wrl <br /> ate 1998 UPGRADE CERTIFICATE NUMBER Tar leod--90 429 <br /> Is 1998 Compliant?Y <br /> UPCF(1/99 revised) - <br />