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FIED PROGRAM CONSOLIDATED FORMI PR#:PR0231861 3 22 b� FAC#:FA0003601 UNDERGROUND STORAGE TANKS - FACILITY (Z (one page per site) TYPE OF ACTION V51.NEW SITE PERMIT ❑3.RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7.PERMANENTLY CLOSED SITE (Check one item only) ❑4.AMENDED PERMIT spmifychan change local use only 8 ❑ 8.TANK REMOVED 6.I EMPORAR} SITE CLOSURE 400 I.FACILITY/SITE INFORMATION 130 S WILSON WAY,STOCKTON BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) g FACILITY ID# I PR ID# ARCO STATION#34690 U&95 FA0003601 PR0231R61 NEAREST CROSS STREET FACILITY OWNER TYPE 401 L]4.LOCAL AGENCY/DISTRICT" WILSON ® 1.CORPORATION ❑5.COUNTY AGENCY* BUSINESS 1.GAS STATION ❑ 3.FARM ❑ 5.COMMERCIAL ❑2.INDIVIDUAL 6.STATE AGENCY* ❑ E]TYPE ❑2.DISTRIBUTOR 4.PROCESSOR ❑ 6.OTHER qp3 ❑ 3.PARTNERSHIP ❑ 7.FEDERAL AGENCY" 402 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 REMAINING AT SITE trustlands? the UST(This is the contact person for the tank records.) 404 ❑ Yes ®No 405 406 11.PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407 PHONFr 408 T_5 the W t tkT NT t_l_L l - 1 MAILING OR STREET ADDRESS 409 CITY 410 STATE C4 411 ZIP CODE '1520S 412 PROPERTY OWNER TYPE ® 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 LLC 52 kil MAILING OR STREET ADDRESS 416 POTOXWm- CITY 417 STATE 418 ZIP CODE 419 A ^�11i� 9Q;a2-603-&_ TANK OWNER TYPE 191 1.CORPORATION ❑2.INDIVIDUAL 1:14.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY 420 ❑ 3.PARTNERSHIP 1:15.COUNTY AGENCY ❑ 7.FEDERAL AGENCY IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY(TK)HQ 44- Call(916)322-9669 if questions arise A21 V.PETROLEUM UST FINANCIAL RESPONSIBILITY INDICATE METHOD(s) 191 1.SELF-INSURED ❑4.SURETY BOND ❑ 7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM ❑2.GUARANTEE ❑5.LETTER OF CREDIT ❑ 8.STATE FUND&CFO LETTER ❑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 for legal notifications and mailing. ® 1.FACILITY ❑2.PROPERTY OWNER ❑3.TANK OWNER 423 Legal notifications and mailing will be sent to the tank owner unless box l or 2 is checked. VII.APPLICANT SIGNATURE Certification-I certify that the information provided herein is true and accurate to the best of my knowledge. SIGNATURE OF APPLICANT DATE 424 PHONE 475 l.� ...-- - 3 r oce 011 20R) L�b6- x(033 NAME OF APPLICANT(print 426 TITLE OF APPLICANT 427 STATE UST FACILITY NUMBER(For local w only) 428 1998 UPGRADE CERTIFICATE NUMBER(For local use onh) 429 Is 1998 Compliant?N UPCF(1/99 revised)