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1D PROGRAM CONSOLIDATED FO <br /> TANKS y%j,, ^G , <br /> UNDERGROUND STORAGE TANKS - FACILITY 3 <br /> (One page per site) Page 1 of 1 <br /> TYPE OF ACTION ❑1.NEW PERMIT [13.RENEWAL PERMIT ®5.CHANGE OF INFORMATION ❑7.PERMANENTLY CLOSED SITE 400' <br /> (Check one item only) ❑4.AMENDED PERMIT (Specify change) ❑S.TANK REMOVED <br /> ❑6.TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Dong B„smess A,) 3. FACILITY <br /> A-1 LIQUORS GAS ID# <br /> NEAREST CROSS STREET 401, FACILITY OWNER TYPE ❑4. LOCAL AGENCY/DISTRICT* 402. <br /> JESSE STREET ❑ 1.CORPORATION ❑5.COUNTY AGENCY* <br /> BUSINESS E 1.GAS STATION ED3.FARM [15.COMMERCIAL 003 [:12.INDIVIDUAL -16.STATE AGENCY* <br /> TYPE [12.DISTRIBUTOR [14.PROCESSOR ❑6.OTHER E 3.PARTNERSHIP [-17.FEDERAL AGENCY* <br /> TOTAL NUMBER OF TANKS 404 Is facility on Indian Reservation 405. *if owner of UST is a public agency:name of supervisor of division, section or 406. <br /> REMAINING AT SITE or trust lands? office which operates the USE. (This is the contact person for the tank records.) <br /> ONE ❑Yes E No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408. <br /> DARSHAN&SURINDER MALHI 209 765-2262 <br /> MAILING OR STREET ADDRESS 409. <br /> 1116 FISHBACK ROAD <br /> CITY 41(Y STATE 411 ZIP CODE 412. <br /> MANTECA CA 95337 <br /> PROPERTY OWNER TYPE ❑ I.CORPORATION [R 2.INDI VIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 413_ <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY <br /> 1I1. TANK OWNER INFORMATION <br /> TANKOWNERNAME 414. PHONE 415. <br /> SAME AS ABOVE <br /> MAILING OR STREET ADDRESS 1420 <br /> CITY 4v, STATE 418. ZIP CODE <br /> TANK OWNER TYPE ❑ I.CORPORATION El 2.INDIVIDUAL [-]4.LOCAL AGENCY/DISTRICT E]6.STATE AGENCY <br /> ❑ 3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY TK H 44- Call 916 322-9669 if questions arise 421 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ❑ 1.SELF-INSURED ❑4.SURETY BOND ❑7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM 422 <br /> ❑2.GUARANTEE ❑5.LETTER OF CREDIT E 8.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 be used for legal notifications and mailing. <br /> Legal notifications and mailings will be sent to the tank owner unless box l or 2 is checked. ❑ 1.FACILITY E 2. PROPERTY OWNER [:13.TANK OWNER 423 <br /> VII. APPLICANT SIGNATURE <br /> Certification'. I certify that the information provided herein is true and accurate to the best ofmy knowledge. <br /> SIGNATURE OF APPLICANG y I DATB 424 PHONE 425. <br /> QZ3- 70153 <br /> NAME OF APPLICANT(Print) 426- TITLE OF APPLICANT 427' <br /> STATE UST FACILITY NUMBER(Agency ase only) 429. 1998 UPGRADE CERTIFICATE NUMBER(Agency are only) 429. <br /> (See Data Element 1,above. <br /> UPCF Hw'fwre-a(1/99)-1/2 http://w .unidoes.org Rev.02/16/00 <br />