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&IED PROGRA-M CONSOLIDATED FO, <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page per site) Page I of-11 <br /> 1 <br /> TYPE OF ACTION C1NEW SITE PERMIT C13.RENEWAL PERMIT El5.CHANGE OF INFORMATION ❑ 7.PERMANCLOSED SITE <br /> (Check one item only) ❑4.AMENDED PERMIT specify change local use only ❑ B.TAMKTLY C REMOVED <br /> ❑6.TEMPO Y SITE CLOSURE ano <br /> I. FACILITY / SITE INFORMATION <br /> RMATION <br /> BUSINESS NAME(Same as FACIILlTY33NAAME or DBA-Doing Business As) 3 FACILITY ID# LT <br /> - - - - <br /> Van De Pol Enterrises W.Charter Wa I I T I <br /> 401 FACILI Y OWNER TYPE Ll 4.LOCAL AGENCYIDISTRICT* <br /> NEAREST CROSS STREET <br /> W.Charter& S.Stockton ® 1.CORPORATION ❑5.COUNTY AGENCY* <br /> BUSINESS ® l.GAS STATION ❑3.FARivI ❑5. COMMERCIAL ❑ 2.INDIVIDUAL [16.STATE AGENCY* <br /> TYPE El2.DISTRIBUTOR C34.PROCESSOR❑6. OTHER 403 ❑ 3.PARTNER SHIP ❑7.FEDERAL AGENCY* aaz <br /> TOTAL NUMBER OF TANKS Is facility on Indian Reservation or *If owne of UST is a public agency:name of supervisor of division,section or office which <br /> REMAINING AT SITE trustlands? operates the UST(This is the contact person for the tank records.) <br /> 5 404 ❑ Yes ® No aos 406 <br /> IL PROPERTY OWNER IN FORMATION <br /> PROPERTY OWNER NAME 45 PHONE 409 <br /> NCC Pro erties 209 466-5086 <br /> 404 <br /> MAILING OR STREET ADDRESS <br /> P.O.Box 1528 <br /> CI1l, 410 STATE all ZIP CODE 412 <br /> Stockton CA 95201 <br /> PROPERTY OWNER TYPE ® 1.CORPORATION 2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY <br /> ❑3.PARTNERSHIP ❑5.QOUNTY AGENCY ❑7.FEDERAL AGENCY 413 <br /> M. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> Van De Pot Enterprises (209)465-4321 <br /> 416 <br /> MAILING OR STREET ADDRESS <br /> 1001 W.Charter Way <br /> CITY 417STATE 418 ZIP CODE 419 <br /> Stockton CA 95201 <br /> TANK OWNER TYPE ® I.CORPORATION ❑2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 420 <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY TK)HQ 44- 1 0 2 1 5 10 1 1 A21 <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s)VI.SELF-INSURED ❑4.SURF-TY BOND ❑7.S ATE FUND ❑ 10.LOCAL GOVT MECHANISM <br /> ❑2.GUARANTEE. ❑5.LETTER OF CREDIT N6,S ATE FUND&CFO GETTER ❑ 99.OTHER: <br /> ❑3.INSURANCE ❑6.EXEMPTION ❑9.S ATE FUND&CD 422 <br /> VI. LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one box to indicate which address should be used for legal notifications and mailing. a23 <br /> Legal notifications and mailings will be sent to the tank owner unless box I or 2 is checked ❑ .FACILITY [12. PROPERTY OWNER ®3.TANK OWNER <br /> VII. APPLICANT SIC NATURE <br /> Certification-I certify that the information provided herein is true and accurate to the best of my knowlec ge. <br /> 425 <br /> SIGN <br /> DAT aza PHONE�FAPPL�ICANT <br /> a?b nA� �F(}� <br /> NAME OF APPLICANT(print) TITL PPLICANT 427�/� <br /> ffiLA1.. > �. YNn� �t� 1• <br /> STATE UST FACILITY NUMBER(For local use only) <br /> 428 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 4z9 <br /> UPCF(1/99 revised) 8 Formerly SWRCB Form A <br />