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01c, 4-o IFIED PROGRAM CONSOLIDATED FORNIP n I? #:PR0231433 �0-7PR FAC ft:FA0003685 UNDERGROUND STORAGE TANKS - FACILITY (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 specify change local useoaly ❑ 8.TANK REMOVED ❑6.TEMPORARY SITE CLOSURE 400 I.FACILITY/SITE INFORMATION 419 S MAIN ST.MANTECA BUSINESS NAME(Same w FACILITY NAME or DBA•Doing Business As) 3 p FACILITY III* PR IDq W/l< S 9(/ 7 X P FA0003685 PR0231433 NEAREST CROSS STREET FACILITY OWNER TYPE ❑4.LOCAL AGENCY/DISTRICT• AfAiN w r / Q 401 CORPORATION M ❑5.COUNTY AGENCY' BUSINESS ErI,GAS STATION ❑ 3.FARM ❑ 5.COMMERCIAL B2 INDIVIDUAL ❑6.STATE AGENCY' TYPE E]2. 3.PARTNERSHIP C] au-' 2.DISTRIBUTOR 4.PROCESSOR ❑ 6.OTHER 403 7.FEDERAL AGENCY' 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.) 3 404 ❑ Yes ® No 405 406 II.PROPERTY OWNER INFORMATION PROPERTY OWNER NAME ao� PHONE Z 3 9 G.}g 408 f�V L.�! 1 /`7 /7��/4 % 209 345=Y122 1 MAILING OR STREET ADDRESS 409 AD R, Y� / 9 S'• /'-I A/N S T DEffCITY O M A 10 TC C A 410 STATE CA al I ZIP CODE f.3-9412 PROPERTY OWNER TYPES CORPORATION -le'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 _ •, _ 41q Li PHONE a1s R(1VTTT-CST ALT//��icLDi L" 209 G1. IrklTL a MAILING OR STREET ADDRESS 416 CITY 417 1 STATE 4111 1 ZIP CODE 419 �ArbtB2T- G4- 9535�- -- TANK OWNER TYPE W:1.CORPORATION U12.INDMDUAL 114.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 420 ❑ 3.PARTNERSHIP ❑ 5.COUNTY AGENCY 117.FEDERAL AGENCY IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY(TK)HQ 44- 44.0. Call(916)322-9669 if questions arise 421 V.PETROLEUM UST FINANCIAL RESPONSIBILITY INDICATE METHOD(s) ❑ 1.SELF-INSURED ❑4.SURETY BOND ❑ 7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM ❑2.GUARANTEE ❑5.LETTER OF CREDIT •V8.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 I or 2 is checked. VII.APPLICANT SIGNATURE Certification-1 certify that the information provided herein is true and accurate to the best of my knowledge. SIGNATURE OF LI(C T DATE 424 PHONE 425 s��3 0 20-5- '-/ o/-S �R 92- NAMEF PLICANT(print) 426 TITLE OF APPLICANT 527 STATE UST FACILITY NUMBER(For local uc only) 428 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 Is 1998 Compliant?Y UPCF(1/99 revised)