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YIFIED PROGRAM CONSOLIDATED FO �/`Q & PR#:PR0231497 �1 FAC#:FA0000279 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 spc*cb-Plow usoonty. ? ❑ 8.TANK REMOVED ❑6.TEMPORARY SITE CLOSURE 400 I.FACILITY/SITE INFORMATION 1097 YOSEMITE AVE,ESCALON BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 FACILITY ID# PR ID# ESCALON MINI MART FA0000279 PR0231497 NEAREST CROSS STREET FACILITY OWNER TYPE E-]4.LOCAL AGENCY/DISTRICT* YOSEMITE 411 ® 1.CORPORATION ❑ 5.COUNTY AGENCY* BUSINESS ❑ 1.GAS STATION ❑ 3.FARM ❑ 5.COMMERCIAL ❑ 2.INDIVIDUAL ❑ 6.STATE AGENCY* TYPE [-] 3.PARTNERSHIP 402 ❑ 2.DISTRIBUTOR ❑4.PROCESSOR E] 6.OTHER 403 E] 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 SINGH,BALWINDER 406 II.PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407 PHONE yob 209 838-0756 MAILING OR STREET ADDRESS 409 1747 BAKER AVE#29 CITY 410 STATE 411 ZIP CODE 412 ESCALON CA 95320 PROPERTY OWNER TYPE O 1.CORPORATION ❑ 2.INDIVIDUAL ❑ 4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY ❑3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY 413 1I1.TANK OWNER INFORMATION TANK OWNER NAME 414 PHONE 415 SINGH,BALWINDER (209)838-1546 MAILING OR STREET ADDRESS 416 1747 BAKER AVE#29 CITY 417 STATE 411 ZIP CODE 419 ESCALON CA 95320 TANK OWNER TYPE ❑ 1.CORPORATION ❑ 2.INDIVIDUAL ❑ 4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY 420 ❑ 3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY TANK OPERATOR INFORMATION TANK OPERATOR NAME TANK OPERATOR TITLE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY(TK)HQ 44- 1 44039786 1 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 D 8.STATE FUND&CFO LETTER ❑99.OTHER ❑3.INSURANCE ❑6.EXEMPTION ❑ 9.STATE FUND&CD 422 V1.LEGAL NOTIFICATION AND MAILING ADDRESS Check one box to indicate which address should be used for legal notifications and mailing. X 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. LJ 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 STAT:UST:FAACILITY NUMBER(For local ue only) 428 1998 UPGRADE CERTIFICATE NUMBER(For local use ony) 429 Is 1998 Compliant?Y UPCF(1/99 revised)