COMPLIANCE INFO_1998-2008 - Laserfiche WebLink

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` FIED PROGRAM CONSOLIDATED FORM Z PR#:PR0231092 • f�3 FAC#:FA0001946 UNDERGROUND STORAGE TANKS -FA L T - , t�V'�' a 1 I03 /i d (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 - ❑ 8.TANK REMOVED ❑6.TEMPORARY SITE CLOSURE 400 I.FACILITY/SITE INFORMATION 1901 S EL DORADO ST.STOCKTON BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 FACILITY ID# TPR ID# DICK N SAVE*/SOHAL MARKET FA0001946 PR0231092 1 NEAREST CROSS STREET 401 FACILITY OWNER TYPE ❑ 4.LOCAL AGENCY/DISTRICT- 7/'p ELDORADO ❑ 1.CORPORATION ❑ 5.COUNTY AGENCY* BUSINESS ® 1.GAS STATION ❑ 3.FARM ❑ 5.COMMERCIAL ❑ 2.INDIVIDUAL * E]TYPE ❑ 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.) a0a C3 , Yes ® No 405 SOHAL,AVTAR 406 fI.PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 401 PHONE 408 AVTAR K SOHAL 209 472-0954 MAILING OR STREET ADDRESS 409 819 NEW HALL CT CITY 410 STATE 411 ZIP CODE 412 STOCKTON CA 95210 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 ats AVTAR K SOHAL MAILING OR STREET ADDRESS 416 819 NEW HALL CT CITY 417 1 STATE 418 ZIP CODE 419 STOCKTON CA 195210 TANK OWNER TYPE ❑X 1,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- 44-024533 Call(916)322-9669 if questions arise 421 V.PETROLEUM UST FINANCIAL RESPONSIBILITY INDICATE METHOD(s) X❑ 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 ❑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. ® 1,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 414 PHONE 425 (209)472-0954 NAME OF APPLICANT(print) 416 TITLE OF APPLICANT an AVTAR K SOHAL OWNER 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)