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'FIED PROGRAM CONSOLIDATED FORM 1 PR a:PRO518114 i6w.0" *J. FAC s FAr UNDERGROUND STORAGE TANKS - FACILITY /9 I (one page per site) TYPE OF ACTION ❑ I.NEW SITE PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION 7.PERMANENTLY CLOSED SITE (Check one item only) ❑ 4,AMENDED PERMIT 8.TANK REMOVED ❑6.TEMPORARY SITE CLOSURE 4W I.FACILITY/SITE INFORMATION 148 E MINER,STOCKTON BUSINESS NAME(Seaen FACRITYNAME.r DBA-Doo,easimss Aa) 3 FACILITY IDN PR IDN MINER&HUNTER PROJECT FA0013700 PR0518114 NEAREST CROSS STREET FACILITY OWNER TYPE ❑4.LOCAL AGENCY/DISTRICT' WI M 1.CORPORATION [1 A COUNTY AGENCY' BUSINESS E] I GAS STATION E] 3.FARM ❑ 5.COMMERCIAL ❑ 2.INDIVIDUAL ❑ 6.STATE AGENCY' TYPE ❑ 2 DISTRIBUTOR ❑4.PROCESSOR ❑ 6.OTHER 103 ❑ 3.PARTNERSHIP402 ❑ ].FEDERAL AGENCY' TOTAL NUMBER OF TANKS Is facility on Indian Reservation or of owner of UST is a public agency:name ofmpmisor of division,section or office which operates REMAINING AT SITE tr istlands? the UST(This is the contact person for the tank records I 4p4 ❑ Yes ®No 403 CITY OF STOCKTON 406 II.PROPERTY OWNER INFORMATION PROPERTY OWNER NAME MI] PHONE 409 MAILING OR STREET ADDRESS 409 CITY 410 1 STATE 411 ZIP CODE 412 PROPERTY OWNER TYPE ❑ I.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 MAILING OR STREET ADDRESS 416 CITY 417 STATE 418 ZIP CODE 419 TANK OWNER TYPE ❑ 1.CORPORATION ❑ 2.INDIVIDUAL ❑ 4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY 420 ❑ 3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY(TK)HQ 44- 1 Call(916)322-9669 if questions Brise 421 V.PETROLEUM UST FINANCIAL RESPONSIBILITY INDICATE METHOD(s) ❑ 1 SELF-INSURED 114.SURETY BOND ❑ 7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM ❑2.GUARANTEE ❑5.LETTER OF CREDIT ❑ 8.STATE FUND&.CFO LETTER ❑99.OTHER 113.INSURANCE ❑6.EXEMPTION ❑ 9.STATE FUND&CD 422 VI.LEGAL NOTIFICATION AND MAILING ADDRESS Check one bon to indicate which address should be used for legal nmificahcor and mailing ❑ I.FACILITY M 2.PROPERTY OWNER ❑3.TANK OWNER 423 Legal notifications and mailing will be sent to the tank owner tadess box 1 or 2 is checked. VII.APPLICANT SIGNATURE Cenificatim.1 cmify that the information provided herein is true and accurate to the best of my knowledge. SIGNATURE OF APPLICANT DATE 424 PHONE 425 NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 422 STATE UST FACILITY NUMBER(I-lmai ae anb) 428 1998 UPGRADE CERTIFICATE NUMBER(Forloc.lus..eh) 429 Is 1998 Compliant? UPCF(1/99 revised)