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Ahk-IFIED PROGRAM CONSOLIDATED FORN& PR#:PRO231438 FAC#:FA0003716 UNDERGROUND STORAGE TANKS - FACILITY (one page per site) TYPE OF ACTION ❑ 1.NEW SITE PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENTLY CLOSED SITE (Check one item only) ❑ 4.AMENDED PERMIT ENNNEMENEEM❑ 8.TANK REMOVED ❑6.TEMPORARY SITE CLOSURE 400 I.FACILITY/SITE INFORMATION 290 N MAIN ST C.MANTECA BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 FACILITY IDI I PR ID# 1 SUPER STOP MARKET* FA0003716 PR0231438 NEAREST CROSS STREET FACILITY OWNER TYPE F-14.LOCAL AGENCY/DISTRICT* MAIN ao1 ® I CORPORATION ❑ 5.COUNTY AGENCY* BUSINESS ❑ 2.INDIVIDUAL 6.STATE AGENCY* aoz TYPE ❑ I•GAS STATION ❑ 3.FARM ❑ 5.COMMERCIAL ❑ ❑ ❑ 2.DISTRIBUTOR E] 3.PARTNERSHIP 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.) 404 ❑ Yes ® No 405 406 II.PROPERTY OWNER INFORMATION PROPERTY OWNER NAME ao7 PHONE 408 MAILING OR STREET ADDRESS 409 PO BOX 1022 CITY 410 STATE 411 1 ZIP CODE 412 MANTECA CA 95336 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 NAMEQ D 414 PHONE 415 EDWARD&DELORES CARD( I°C I (�l�Nae e T i-1 A �E 2 ^ D3`) Li Ll MAILING OR STREET ADDRESS c�.i a C 1 cl O A rN S)P- C e YeS a 16 PO BOX 1022 �S CA `�J n"01 ��I CITY 417 1 STATE 418 1 ZIP CODE 419 MANTECA CA 95336 TANK OWNER TYPE ❑ I.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- - 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 LETTER 19199.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. ® I.FACILITY ❑2.PROPERTY OWNER ❑3.TANK OWNER 423 Legal notifications and mailing will be sent to the tank owner unless box 1 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 1 PHONE 425 NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 427 STATE UST FACILITY NUMBER(For local ue only) 428 1998 UPGRADE CERTIFICATE NUMBER(For Iocai use only) 429 Is 1998 Compliant?Y UPCF(1/99 revised)