Laserfiche WebLink
0 <br /> IFIED PROGRAM CONSOLIDATED FORM FAC#:FA0003679 <br /> 555 <br /> * w UNDERGROUND STORAGE TANKS -FA ILT /�2 16)_ <br /> (one page per site) <br /> TYPE OF ACTION ❑ 1.NEW SITE PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENTLY CLOS SITE <br /> (Check one item only) <br /> ❑4.AMENDED PERMITIWO <br /> ,. ❑ 8.TANK REMOVED <br /> ❑6.TEMPORARY SITE CLOSURE J 4 D <br /> I.FACILITY/SITE INFORMATION 2224 MANTHEY RD,STOCKTON <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) g FACILITY ID# PR ID# <br /> CALIFORNIA STOP* FA0003679 PR0232555 <br /> NEAREST CROSS STREET FACILITY OWNER TYPE ❑4.LOCAL AGENCY/DISTRICT* <br /> MANTHEY 401 ❑ 1.CORPORATION ❑ 5.COUNTY AGENCY' <br /> BUSINESS N 1.GAS STATION ❑ 3.FARM ❑ 5.COMMERCIAL [:1 2.INDIVIDUAL <br /> TYPE [:] ❑ [1E] 6.STATE AGENCY* <br /> 2.DISTRIBUTOR 4.PROCESSOR 6.OTHER 403 ❑ 3.PARTNERSHIP ❑ 7.FEDERAL AGENCY* 402 <br /> TOTAL NUMBER OF TANKS Is facility on Indian Reservation or *Ifowner of UST is a public agency:name of supervisor of division,section or office which operates <br /> REMAINING AT SITE trustlands? the UST(This is the contact person for the tank records.) <br /> 404 ❑ Yes N No 405 406 <br /> Il.PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408 <br /> LE NHUAN T&PHAN DUNG T <br /> MAILING OR STREET ADDRESS 409 <br /> 2053 HOUSTON AVE <br /> CITY 410 1 STATE 411 ZIP CODE 412 <br /> STOCKTON CA 95206 <br /> PROPERTY OWNER TYPE ❑ 1.CORPORATION ❑ 2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY <br /> [913.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY 413 <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> LE NHUAN T&PHAN DUNG T <br /> MAILING OR STREET ADDRESS 416 <br /> 2053 HOUSTON AVE <br /> CITY 417 1 STATE 418 1 ZIP CODE 419 <br /> STOCKTON CA 95206 <br /> TANK OWNER TYPE 0 1.CORPORATION ❑ 2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY 420 <br /> ❑ 3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 1 Call(916)322-9669 if questions arise 421 <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ❑ 1.SELF-INSURED ❑4.SURETY BOND ❑ 7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM <br /> ❑2.GUARANTEE ❑5.LETTER OF CREDIT ❑ 8.STATE FUND&CFO LETTER M1 99.OTHER <br /> ❑3.INSURANCE ❑6.EXEMPTION ❑ 9.STATE FUND&CD 422 <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one box to indicate which address should be used for legal notifications and mailing. ® 1.FACILITY ❑2.PROPERTY OWNER ❑3.TANK OWNER 423 <br /> Legal notifications and mailing will be sent to the tank owner unless box 1 or 2 is checked. <br /> VII.APPLICANT SIGNATURE <br /> Certification-I certify that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNATURE OF APPLICANT DATE 424 1 PHONE 425 <br /> NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 427 <br /> STATE UST FACILITY NUMBER(For local ue only) 428 1 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 <br /> Is 1998 Compliant?Y <br /> UPCF(1/99 revised) <br />