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Al jq-7 NNIFIED PROGRAM CONSOLIDATED FORM PRN:PRO522519 �2 Jl FAC,4y:FA0015 37 12atlaC UNDERGROUND STORAGE TANKS - FACIL (one page per site) TYPE OF ACTION ❑ 1.NEW SITE PERMIT ❑3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION x�❑ 7.PERMANENTLY CLOSED SITE (Check one item only) ❑ 4.AMENDED PERMIT s,exavchangcloceluubah, ^{ 8.TANK REMOVED ❑6.TBMPORARY SITE❑.OSII RF 40a I.FACILITY/SITE INFORMATION 1130 S PILGRIM ST,STOCKTON BUSINESS NAMES.as FACILITY NAME re DBA-Doing Business A4) 3 FACILITY IDN I PR IDN ISLAMIC CENTER FA0015337 PRO522519 1 NEAREST CROSS STREET FACILITY OWNER TYPE ❑ 4,LOCAL AGENCY/DISTRICT' 401 ® I.CORPORATION ❑ 5.COUNTY AGENCY' BUSINESS ❑ 1,GAS STATION ❑ 3.FARM ❑ 5.COMMERCIAL ❑ 2.INDIVIDUAL ❑ 6,STATE AGENCY' TYPE ❑ y DISTRIBUTOR ❑ 4.PROCESSOR ❑ 6.OTHER 403 ❑ 3.PARTNERSHIP [-1 402 7.FEDERAL AGENCY' TOTAL NUMBER OF TANKS Is facility on Indian Reservation or *If owner of UST is a public agency.time of supervisor of division,section or office which operates REMAINING AT SITE trustlands? the UST(This is the contact person for the tank records.) arta ❑ Yes M No 405 ISLAMIC CENTER 406 IL PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407 PHONE 408 ISLAMIC CENTER 0- MAILING OR STREET ADDRESS 405 Same As Site CITY 410 STATE 4U ZIPCODE 412 Same As Site Same As Site Same As Site PROPERTY OWNER TYPE ❑ 1.CORPORATION ❑ 2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY ❑3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY 413 III.TANK OWNER INFORMATION TANK OWNER NAME 414 PHONE 415 ISLAMIC CENTER 0- MAILING OR STREET ADDRESS 416 1130 S PILGRIM ST CITY 417 STATE 418 ZIP CODE 419 Same As Site Same As Site Same As Site TANK OWNER TYPE Ell.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- Call(916)322-9669 if questions arise 421 V.PETROLEUM UST FINANCIAL RESPONSIBILITY INDICATE METHOD(s) ❑ I SELF-INSURED ❑4.SURETY BOND ❑ 7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM ❑2.GUARANTEE ❑ 5.LETTER OF CREDIT ❑ 8.STATE FUND&CFO LETTER I]99.OTHER ❑3.INSURANCE ❑6.EXEMPTION ❑ 9.STATE FUND&CD "D VI.LEGAL NOTIFICATION AND MAILING ADDRESS Check one box to indicate which address should be used for legal notifications and mailing. ❑ 1.FACILITY ®2.PROPERTY OWNER ❑3.TANK OWNER 423 Legal notifications and mailing will be sent to the tank owner unless box I or 2 is checked. VII.APPLICANT SIGNATURE Certification-I certify that the information provided herein is true and accurate to the best of my knowledge. SIGNATURE OF APPLICANT DATE 424 PHONE 425 NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 427 STATE UST FACILITY NUMBER(For Ima1 m onb) 428 1 1998 UPGRADE CERTIFICATE NUMBER For Imal me only) 429 Is 1998 Compliant? UPCF(1/99 revised)