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lo7 11-U-02 ED PROGRAM CONSOLIDATED FO r� PR #: PR0231488 ��0`�Z FAC #: FA0003910 UNDERGROUND STORAGE TANKS - FACILITY (one page per site) TYPE OF ACTION ❑ 1. 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 2501 JACKSON AVE. ESCALON BUSINESS NAME (Same as FACILrrY NAME or DBA - Doing Business As) 3 FACILITY PR ID# ID# H & M MARKET FA0003910 PR0231488 1 NEAREST CROSS STREET FACILITY OWNER TYPE E]4. LOCAL AGENCY/DISTRICT« JACKSON aol ❑ 1. CORPORATION ❑ 5. COUNTY AGENCY* ❑ 2. INDIVIDUAL E] 6. STATE AGENCY BUSINESS ❑ 1. GAS STATION ❑ 3. FARM ® 5. COMMERCIAL TYPE ❑ 2. DISTRIBUTOR ❑ 4. PROCESSOR [j6.OTHER 403 ❑ 3. PARTNERSHIP ❑ 7. FEDERAL AGENCY' 402 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 REMAINING AT SITE trustlands? the UST (This is the contact person for the tank records.) 404 ❑ Yes ® No 405 406 II. PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407 PHONE aoa PHIL MATHEWS 408 336-2549 MAILING OR STREET ADDRESS 409 532 COON HEIGHTS RD CITY 410 STATE 411 ZIP CODE 412 BEN LOMAN CA 95005 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 C1B & W PETROLEUM - 2 MAILING OR STREET ADDRESS 416 POLI -099 {fin Ooh( 6-1U7.1-7 CITY 417 M STATE 419 ZIP CODE 419 5 -SAtrDA D tStg CA TANK OWNER TYPE 1. CORPORATION ❑ 2. INDIVIDUAL ❑ 4. LOCAL AGENCY / DISTRICT ❑ 6. STATE AGENCY ago ❑ 3. PARTNERSHIP 115. COUNTY AGENCY ❑ 7. FEDERAL AGENCY IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY (TK) HQ 44- 44-029058 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 ❑ 8. STATE FUND & CFO LETTER 9199. 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 424 1 PHONE 425 NAME OF APPLICANT (print) 426 TITLE OF APPLICANT 427 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)