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IED PROGRAM CONSOLIDATED FORM PR#:PRO518442 FAC#:F1013913 UNDERGROUND STORAGE TANKS - FACILITY 1-53 \xV / (one page per sill TYPE OF ACTION ❑ L NEW SITE PERMIT ❑ 3.RENEWAL PERMIT 5.CHANGE OF INFORMATION ❑ 7.PERMANENTLY CLOSED SITE (Check one item only) ❑ 4,AMENDED PERMIT ❑ S TANK REMOVED ❑6.TEMPORARY SITE CLOSURE 400 I.FACILITY/SITE INFORMATION 640 N SAN JOAQUIN,STOCKTON BUSINESS NAME(somn.s FACILITY NAME or DBA-Doing Buincss As) 3 FACILITY M# PR ID# HERITAGESQUARE FA0013913 PRO518442 NEAREST CROSS STREET FACILITY OWNER TYPE 401 ® 1.CORPORATION ❑4.LOCAL /DISTRICT' ❑ 5.COUNTYY AGENCY' BUSINESS ❑ I.GAS STATION ❑ 3.FARM ❑ 5.COMMERCIAL ❑ 2.INDIVIDUAL ❑ 6.STATE AGENCY' TYPE ❑ 2 DISTRIBUTOR ❑4.PROCESSOR ❑ 6.OTHER 403 ❑ 3.PARTNERSHIPEl402 7.FEDERAL AGENCY' TOTAL NUMBER OF TANKS Is facility on Indian Reservation or 'If owner of UST is a public agency:name of supervisor of division,section or office which operates REMAINING AT SITE tr tstlands? the UST(This is the contact Person for the tank records.) +0+ ❑ Yes ® No 409 DAVID AND MARIANNE WARWICK 406 11.PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407 PHONE 408 MAILING OR STREET ADDRESS 400 CITY 410 STATE 411 ZIP CODE 412 PROPERTY OWNER TYPE ❑ 1.CORPORATION ❑ 2.INDIVIDUAL El 4.LOCAL AGENCY/DISTRICT El 6.STATE AGENCY E13.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY 413 . III.TANK OWNER INFORMATION TANK OWNER NAME 414 PHONE 415 MAILING OR STREET ADDRESS 416 CITY 417 1 STATE 41g ZIP CODE 419 TANK OWNER TYPE ❑ I.CORPORATION ❑ 2.INDIVIDUAL ❑ 4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY 420 ❑ 3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY W.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY(TK)HQ 44- 1 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 GOVT MECHANISM ❑2.GUARANTEE ❑ 5.LETTER OF CREDIT ❑ 8.STATE FUND&CFO LETTER 1:199.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. ❑ 1.FACILITY M 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 I.]..oh) 428 1998 UPGRADE CERTIFICATE NUMBER(F«i=imiv) 420 Is 1998 Compliant? UPCF(1/99 revised)