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UNIFIED PROGRAM CONSOLIDATED FORM DEC y 4 2007 <br /> �ll TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY ENVIRONMENT NEA' N <br /> (One pa 0,T/ ) <br /> TYPE OF ACTION ❑ 1.NEW PERMIT ❑3.RENEWAL PERMIT ®5.CHANGE OF INFORMATION ❑7.PERMANENTLY CLOSED SITE 400. <br /> (Check one item only) ❑4.AMENDED PERMIT(Specify change) ❑8.TANK REMOVED <br /> ❑6.TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Same as FACILITY NAIVE or DBA-Doing Business As) 3, FACILITY <br /> Rai Gas Stations,Inc.dba March Lane 76 ID# 1. <br /> NEAREST CROSS STREET 401. FACILITY OWNER TYPE 4.LOCAL AGENCY/DISTRICT* 402• <br /> West Lane and East March Lane ® 1.CORPORATION ❑5.COUNTY AGENCY* <br /> BUSINESS ® 1.GAS STATION ❑3.FARM [15.COMMERCIAL 403• [:12.INDIVIDUAL ❑6.STATE AGENCY* <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR [16.OTHER ❑3.PARTNERSHIP ❑7.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 UST. (This is the contact person for the tank records.) <br /> 3 ❑Yes ®No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407• PHONE 408, <br /> Petros Rai Stations,LLC (209)478-6487 <br /> MAILING OR STREET ADDRESS 409 <br /> 10944 Flaming Star Lane <br /> CITY 410. STATE 411. ZIP CODE <br /> 412. <br /> Stockton CA 95209 <br /> PROPERTY OWNER TYPE 0 1.CORPORATION 2.INDIVIDUAL Lj 4.LOCAL AGENCY/DISTRICT Lj 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 /> Petros Rai Stations,LLC (209)478-6487 <br /> MAILING OR STREET ADDRESS 416. <br /> 10944 Flaming Star Lane <br /> CITY 417. 1 STATE 418. ZIP CODE 419. <br /> Stockton CA 95209 <br /> TANK OWNER TYPE ® 1.CORPORATION ❑2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT [16.STATE AGENCY 420. <br /> ❑3.PARTNERSHIP [:15.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- Call(916)322-9669 if questions arise 421. <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ❑I.SELF-INSURED ❑4.SURETY BOND ❑7.STATE FUND ❑10.LOCAL GOVT MECHANISM 422 <br /> ❑2.GUARANTEE ❑5.LETTER OF CREDIT ®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 I or 2 is checked. ❑ 1.FACILITY ®2. PROPERTY OWNER ❑3.TANK OWNER 423. <br /> VII.APPLICANT SIGNATURE <br /> Certification: I certify that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNATURE OF APPLICANT DATE ata. <br /> PHONE 42s. <br /> /o2 (209)478-6487 <br /> NAME OF APPLICANT(print) 426. TITLE OF APPLICANT 427. <br /> Amarjit S.Rai Owner/Operator <br /> STATE UST FACILITY NUMBER(Agency use only) 428. 1998 UPGRADE CERTIFICATE NUMBER(Agency use only) 429• <br /> (See Data Element 1,above. <br /> UPCF Hwfwrc-a(1/99)-1/2 www.unidocs.org Rev.02/16/00 <br />