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UNIFIED PROGRAM CONSOLIDATED FORM PR#:PR0231667 <br /> • FAC#:FA0002121 <br /> UNDEF�ROUND STORAGE TANKS -AD <br /> MITY 01) I bA�Q� <br /> (one page per site) <br /> TYPE OF ACTION ❑ 1.NEW SITE PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENTLY CLOSED SITE <br /> (Check one item only) ❑4.AMENDED PERMIT ❑ 8.TANK REMOVED <br /> ❑6.TEMPORARY SITE CLOSURE 40n <br /> I.FACILITY/SITE INFORMATION 4075 E MAIN ST,STOCKTON <br /> BUSINESS NAME(ssmeas FkMLL NA E9 DBA-Do,Bmb.,As) 3 FACB.TTYID# PR IDN <br /> JAMAR SERVICE FA0002121 PR0231667 1 <br /> NEAREST CROSS STREET 401 FACT I I V.05PNER TYPE ❑ 4.LOCAL AGENCY/DISTRICT- <br /> MAIN ❑ I ORPORATION ❑ 5.COUNTY AGENCY* <br /> NIDUAL <br /> BUSINESS z.IND <br /> 1.GAS STATION ❑ 3.FARM ❑ 5.COMMERCIAL ❑ b.STATE AGENCY* <br /> TYPE ❑ 2.DISTRIBUTOR ❑4.PROCESSOR ❑ 6.OTHER 403 ❑ 3.PARTNERSHIP ❑ 7.FEDERAL AGENCY* 403 <br /> 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 <br /> REMAINING AT SITE tm <br /> stlands? the UST is the contact person for bank records.) <br /> v 404 ElYes M No 405 MCILRATH,JAY 406 <br /> II.PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 4m PHONE 409 <br /> ,TIL Y1 jC Z 209 477-7787 <br /> MAILING OR STREET ADDRESS 404 <br /> 14 W LONGVIEW <br /> CITY 410 STATE 411 ZIP CODE 412 <br /> STOCKTON I CA 95207 <br /> PROPERTY OWNER TYPE 1.CORPORATION 2.INDIVIDUAL ❑ 4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY <br /> El3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY 413 <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> JAMAR SERVICE 209 477-7787 <br /> MAII.INO OR STREET ADDRESS 416 <br /> PO BOX 326 <br /> CITY 419 STATE419 ZIP CODE 419 <br /> STOCKTON CA 95201 <br /> TANK OWNER TYPE ❑X I.CORPORATION ❑ 2.INDIVIDUAL 114.LOCAL AGENCY/DISTRICT 116.STATE AGENCY 420 <br /> ❑ 3.PARTNERSHIP ❑ 5.COUNTY AGENCY 117.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 44-024816 1 Call(916)322-9669 if questions arise 421 <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ❑ 1,SELF-INSURED ❑4.SURETY BON) ❑ .7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM <br /> ❑2.GUARANTEE ❑ 5.LETTER OF CREDIT 2r 8.STATE FUND&CFO LETTER ❑X 99.OTHER <br /> ❑3.INSURANCE ❑6.EXEMPTION ❑ 9.STATE FUND&CD 422 <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one box to indicate whichaddress should be used for legal notifications and mailing. ® LFACIIITY ❑2.PROPERTY OWNER El 3.TANK OWNER 423 <br /> Legal notifications and mailing will be sent to the tank owner unless box 1 or 2 is checked. <br /> VIL APPLICANT SIGNATURE <br /> Certification.I certify[bat the information provided herein is one and accurate to the best of my knowledge. <br /> SIGNATURA0PLJCANT DATENAME OF (print) 426 TITLE OF APPLICANT 427 <br /> a? l sic C`4c-�AJ e�- <br /> STATE UST FACILITY NUMBER(Fmloml or ooh) 428 1998 UPGRADE CERTIFICATE NUMBER(Fmled me only) 429 <br /> Is 1998 Compliant?Y <br /> UPCF(1/99 revised) <br /> 4 <br />