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_ V. Illi h) IFIED PROGRAM CONSOLIDATED FO I U R#:PR0231876 FAC#:FA0000421 UNDERGROUND STORAGE TANKS - FACILITY ♦ �1 oC 7 age per site) TYPE OF ACTION ❑ L NEW SITE PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENTLY CLOSED SITE (Check one item only) ❑ 4,AMENDED PERMIT ;, ❑ 8.TANK REMOVED ❑6.TEMPORARY SITE CLOSURE 400 1.FACILITY/SITE INFORMATION 1001 E YOSEMITE AVE,MANTECA BUSINESS NAME(same as FAC TYNAME or DBA-Doing Business As) 3 FACILITY IDI PR ID# 1. ' _Q_,,S F FA0000421 PR0231876 l 0. NEAREST CROSS S'Itcrc f 401 FACILITY OWNER TYPE ❑ 4.LOCAL AGENCY/DISTRICT* ® 1.CORPORATION �J ❑ 5 COUNTY AGENCY* BUSINESS ❑ 1 GAS STATION r❑ 3.6RM ❑ 5.COMMERCIAL ❑ 2.INDIVIDUAL ❑ 6.STATE AGENCY* TYPE ❑ E] E] 3.PARTNERSHIP 402 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.) 404 ❑ Yes IN No 405 406 II.PROPERTY OWNER INFORMATION PROPERTY OWNER NAME am PHONE 408 DARAKR INC 925 945-1158 MAILING OR STREET ADDRESS 409 690 YGNACIO VALLEY RD CITY 410 STATE 411 ZIP CODE 412 WALNUT CREEK CA 1 94596 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 DARAKR INC (925)945-1158 MAILING OR STREET ADDRESS 416 690 YGNACIO VALLEY RD CITY 417 STATE 418 ZIP CODE 419 WALNUT CREEK I CA 94596 TANK OWNER TYPE ❑X 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- 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 1:15.LETTER OF CREDIT ❑ 8.STATE FUND&CFO LETTER ❑99.OTHER ❑D 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. 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-1 certify that the information provided herein is true and accurate to the best of my knowledge. SIGNATURE OF APPLICANT DATE 424 PHONE 425 (2�►L�D(� (209) 824-9282 NAME OF APPLICANT(print) 426 TITLE OF APPLICANT �y� 427 C- �, A1(&Q r NC BUSINESS OWNER k"A _"()eAS�d STATE UST FACILITY NUMBERFor local ue only) 428 1998 UPGRADE CERTIFICATE NUMBER(For local use ouly) 429 ( y) Is 1998 Compliant?Y UPCF(1/99 revised)