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W DAA -Le -02 1 ED PROGRAM CONSOLIDATED FORM r / Z PR#:PRO231433 t i l bo b FAC#: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 a local use�y ❑ 8.TANK REMOVED ❑6.TEMPORARY SITE CLOSURE 400 I.FACILITY/SITE INFORMATION 419 S MAIN ST.MANTECA BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 FACILITYID# PR ID# TIll I BOYETT PETROLEUM FA0003685 PR0231433 NEAREST CROSS STREET FACILITY OWNER TYPE ❑4.LOCAL AGENCY/DISTRICT' MAIN aot ❑ L CORPORATION ❑ S.COUNTY AGENCY* BUSINESS ® 1.GAS STATION ❑ 3.FARM ❑ 5.COMMERCIAL ❑ 2.INDIVIDUAL TYPE ❑ E] El 6.STATE AGENCY" 2.DISTRIBUTOR 4.PROCESSOR ❑ 6.OTHER 403 ❑ 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 El Yes ®No 405BOYETT PETROLEUM 406 II.PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407 PHONE 408 BOYETT STAN/CARL/DALE 209 545-1122 MAILING OR STREET ADDRESS 409 PO BOX 1099 CITY 410 STATE 411 ZIP CODE 412 SALIDA CA 95368 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 BOYETT STAN/CARL/DALE 209 545-1122 MAILING OR STREET ADDRESS 416 f-e-B E)x- � PD BOX -IU Z.1-7 - CITY 417STATE 418 ZIP CODE 4t9 A C5� CA tea- q 5 35`1 TANK OWNER TYPEX❑ 1.CORPORATION ❑ 2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT 116.STATE AGENCY 420 ❑ 3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY(TK)HQ 44- 44-029058 F 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 ❑ 8.STATE FUND&CFO LETTER7C❑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. El 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-I certify 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 417 STATE UST FACILITY NUMBER(For local ue only) 428 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 Is 1998 Compliant?Y UPCF(1/99 revised)