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t <br /> IF IED PROGRAM CONSOLIDATED F <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page per site) <br /> TYPE OF ACTION ❑ 1.NEW SITE PERMIT [:13.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENTLY CLOSED SITE <br /> (Check one item only) ❑4.AMENDED PERMIT ❑ 8.TANK REMOVED <br /> ❑6.TEMPORARY SITE CLOSURE 400 <br /> I.FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Same as FACILITY NnME or DBA-Doing Business As) 3 FACILITY ID# <br /> DICK N SAVE* FA0001946 1 <br /> T � FT <br /> NEAREST CROSS STREET FACILITY OWNER TYPE ❑4.LOCAL AGENCY/DISTRICT* <br /> aoI <br /> ❑ 1.CORPORATION ❑ 5.COUNTY AGENCY* <br /> BUSINESS ❑ 1.GAS STATION ❑ 3.FARM ❑ 5.COMMERCIAL ® 2.INDIVIDUAL" ❑6.STATE AGENCY* <br /> TYPE ❑ 2.DISTRIBUTOR [:14.PROCESSOR ❑6.OTHER 403 ❑ 3.PARTNERSIIIPao2 <br /> ❑ 7.FEDERAL AGENCY* <br /> 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 <br /> REMAINING AT SITE trustlands? operates the UST(This is the contact person for the tank records.) <br /> 6 404 ❑Yes ®No 405 406 <br /> II.PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME ao7HONE 408 <br /> MOHAMAD S MATAR 209 948-3009 <br /> MAILING OR STREET ADDRESS 409 <br /> 1314 DEB CT <br /> CITY 410 STATE 411 ZIP CODE 412 <br /> SAN JOSE CA 95120 <br /> PROPERTY OWNER TYPE ❑ 1.CORPORATION ® 2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY <br /> 03.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY ata <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> MOHAMAD S MATAR 209 948-3009 <br /> MAILING OR STREET ADDRESS 416 <br /> 1314 DEB CT <br /> CITY 417[STATE 418 ZIP CODE 419 <br /> SAN JOSE CA 95206 <br /> TANK OWNER TYPE ❑ 1.CORPORATION x❑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- T44-024533 I 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 1:199.OTHER <br /> 1913.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 1:13.TANK OWNER 423 <br /> Legal notifications and mailing will be sent to the tank owner unless box I 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 I PHONE 425 <br /> (209)948-3009 <br /> NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 427 <br /> MOHAMAD S MATAR OWNER <br /> STATE UST FACILITY NUMBER(For local ue only) 428 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 <br /> N <br /> UPCF(1/99 revised) <br />