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L?i evol <br /> �FIED PROGRAM CONSOLIDATED FOk,,.� <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY kJ q l�(I06� D <br /> " <br /> (One page per site) Page_of <br /> TYPE OF ACTION ®1.NEW PERMIT ❑3.RENEWAL PERMIT ❑5.CHANGE OF INFORMATION [17.PERMANENTLY CLOSED SITE <br /> (Check one item only) [14.AMENDED PERMIT (Specify change) ❑8.TANK REMOVED <br /> ❑6.TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-wing Business An 3, 1 FACILITY <br /> Great American Gas&Car Wash IDN <br /> NEAREST CROSS STREET 401, FACILITY OWNER TYPE ❑4.LOCAL AGENCY/DISTRICT* wz. <br /> Yosemite&Ai OlY ®1.CORPORATION ❑5.COUNTY AGENCY' <br /> BUSINESS 1.GAS STATION 3.FARM ❑5.COMMERCIAL 4a1 ❑2.INDIVIDUAL ❑6.STATE AGENCY* <br /> TYPE ❑2.DISTRIBUTOR [14.PROCESSOR ❑6.OTHER ❑3.PARTNERSHIP ❑7.FEDERAL AGENCY* <br /> TOTAL NUMBER OF TANKS 404_ Is facility on Indian Reservation 005. a If owner of UST is a public agency: name of supervisor of division,section or 405. <br /> REMAINING AT SITE or trust lands? office which operates the UST. (This is the contact person for the tank records.) <br /> 3 ❑Yes ''ANo <br /> 11. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407, PHONE 408. <br /> Gasspecs,Inc. (209)321-1062 <br /> MAILING OR STREET ADDRESS 409. <br /> 1883 Rochester St. <br /> CITY 410. STATE 411. ZIP CODE 412. <br /> Tracy I CA 95377 <br /> PROPERTY OWNER TYPE ® 1.CORPORATION Lj 2.INDIVIDUAL Lj 4.LOCAL AGENCY/DISTRICT 0 6.STATE AGENCY 413. <br /> ❑3.PARTNERSHIP [15.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> Gass ecs,.Inc. (209)321-1062 <br /> MAILING OR STREET ADDRESS 416. <br /> 1883 Rochester St. <br /> CITY 417 STATE 418. ZIP CODE 439. <br /> Tracey CA 95377 <br /> TANK OWNER TYPE ® 1.CORPORATION 2.INDIVIDUAL Lj 4.LOCAL AGENCY/DISTRICT [16.STATE AGENCY 420. <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY TK HQ 44- 1 1 1 1 1 1 1 Call (916)322-9669 if questions arise 421_ <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ❑1.SELF-INSURED [14.SURETY BOND [17.STATE FUND [110.LOCAL GOVT MECHANISM 422 <br /> ❑2.GUARANTEE [15.LETTER OF CREDIT [18.STATE FUND&CFO LETTER ❑99.OTHER: <br /> ❑3.INSURANCE ❑6.EXEMPTION ❑9.STATE FUND&CD <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one box to indicate which address should he used for legal notifications and mailing. <br /> Legal notifications and mailings will be sent to the tank owner unless box 1 or 2 is checked. ❑ L FACILITY [:12. PROPERTY OWNER ❑3.TANK OWNER 423. <br /> VIL APPLICANT SIGNATURE <br /> Cernficat n: certify thXpAtf4uaillum provided herein is true and accurate to the best of my krowledge. <br /> SIGNA C DA E / 424 PHONE 425- <br /> u-o t <br /> NAME OF NT(pri ) 426. TITLE OF APPLICANT 427 <br /> STATE UST FACILITY NUMBER(Agency use nnly) 428. 1998 UPGRADE CERTIFICATE NUMBER(Agency use oNy) 429. <br /> (See Data Element 1,above. <br /> UPCF Hwfwrc-a(1/99)-1/2 http://www.unidoc&org Rev.02/16/00 <br />