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• �NIFIED PROGRAM CONSOLIDATED FOP* PR#:PR0231459 J FAC#:FA00036n UNDERGROUND STORAGE TANKS -FACILITY �1 Lb(2)t03 (one page per site) 6 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 ❑ 8.TPNRItkMOVED ❑6.TEMPORARY SITE CLOSURE U 400 I.FACILITY/SITE INFORMATION 824 E YOSEMITE AVE.MANTECA BUSINESS NAME(s.me as FACn.rrvNA14E or DSA-Doing em;nes As) 3 FACILITY D)# PR ID# GAS DEPOT FA0003677 PR0231459 NEAREST CROSS STREET FACILITY OWNER TYPE Mt ❑El 1.CORPORATION 4.LOCAL /DISTRICT' YOSEMITE �{ [:1S.COUNTY AGEN AGENCY• BUSINESS ® 1.GAS STATION ❑3.FARM E] 5.COMMERCIAL X2.INDIVIDUAL ❑ 6.STATE AGENCY' TYPE ❑ 2.DISTRIBUTOR ❑ 4.PROCESSOR ❑ 6.OTHER 403 ❑ 3.PARTNERSHIP ❑ 402].FEDERAL AGENCY* TOTAL NUMBER OF TANKS Is facility on Indian Reservation or •lfownm of UST is a public agency:more of supervisor ofdivision,section or office which operates REMAINING AT SITE trustlands? the UST(This is the contact person for the tank records.) 404 ❑ Yes M No 405 406 H.PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407PHONE 408 SEUNG Y HUR MAILING OR STREET ADDRESS seg Same As Site CITY 410 1 STATE 411 ZIP CODE 412 Sarre As Site Same As Site Same As Site PROPERTY OWNER TYPE ..99 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 SEUNG Y HUR 209 823-5717 MAILING OR STREET ADDRESS 416 824 E YOSEMITE AVE CITY 417 STATE 418 ZIP CODE 419 Same As Site Same As Site Same As Site TANKOWNERTYPE ,fit CORPORATION 2.INDIVIDUAL El 4.LOCAL AGENCY/DISTRICT 116.STATE AGENCY 420 ❑ 3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑7.FEDERAL AGENCY IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY(TK)HQ 44- 44-024702 1 Call(916)322-9669 if questions arise 421 V.PETROLEUM UST FINANCIAL RESPONSIBILITY INDICATE METHOD(s) ❑ 1.SELF-INSURED 114.SURETY BOND ❑ 7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM 1-12.GUARANTEE 115.LETTER OF CREDIT ❑ 8.STATE FUND&CFO LETTER El 99.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 Por legal notifications and mailing. ® I.FACILITY ❑2.PROPERTY OWNER E] 3.TANK OWNER 423 Legal notifications and smiling will be sent to the unk owner unless box 1 or 2 is checked. VII.APPLICANT SIGNATURE Certification-I certify that the information provided herein is true and accurate to the best ofmy,knowledge. SIGNATURE OF APPLICANT DATE 424 1 PHONE 425 NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 427 STATE UST FACILITY NUMBER(rarlomlurcnly) 428 1998 UPGRADE CERTIFICATE NUMBER(Forlord we wy) 429 Is 1998 Compliant?Y UPCF(1/99 revised)