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` IFIED PROGRAM*CONSOLIDATED FOR PR#:PR0231911 ` FAC#:FA0000540 UNDERGROUND STORAGE TANKS - FACILITY (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) r: �'T ( Y) ❑ 4.AMENDED PERMIT spOff-d ;" '^'"?�'� , ❑ 8.TANK REMOVED ❑6.TEMPORARY SITE CLOSURE 400 L FACILITY/SITE INFORMATION 14971 N HWY 88,LODI BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Busimss As) 3 FACILITY ID# PR ID# COUNTRYSIDE MINI MART FA0000540 PR0231911 NEAREST CROSS STREET FACILITY OWNER TYPE ❑ 4.LOCAL AGENCY/DISTRICT' HWY 88 401 N 1.CORPORATION ❑ 5.COUNTY AGENCY' BUSINESS 147 I GAS STATION ❑ 3.FARM ❑ 5.COMMERCIAL ❑ 2.INDIVIDUAL ❑ 6.STATE AGENCY* TYPE !� ❑ 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 N No 405 406 II.PROPERTY OWNER INFORMATION PROPERTY OWNER NAME CAA;?f fff 1 Eb-Tc! ,J_(&x �y+' rew - L- 402 PHONE 408 MAILING OR STREET ADDRESS I l i .q -H�/ V �J � �' 8 S ��`) 409 Ac Cte � Cama CITY alo STATE 411 ZIP CODE 412 PROPERTY OWNER TYPE N 1.CORPORATION ❑ 2.INDIVIDUAL ❑ 4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY E-13.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY 413 III.TANK OWNER INFORMATION TANK OWNER NAME r^ 414 PHONE 415 MAILING OR STREET ADDRESS 416 114971 *r r rcn�nn. CITY 417 STATE 418 ZIP CODE 419 am5�'Stt1t- SanTe-AT6ite TANK OWNER TYPE X❑ L CORPORATION ❑ 2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT 1:16.STATE AGENCY 420 ❑ 3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY IV.BOARD OF EQUALIZATION UST STORAGE FEE A COUNT NUMBER TY(TK)HQ 44- ABs- all(916)322-9669 if ques-ons arise 421 V.PETROLEUM UST FINANCIA PONSIBI INDICATE METHOD(s) ❑ 1.SELF-INSURED ❑4.SURETY BOND ❑ 7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM ❑2.GUARANTEE ❑5.LETTER OF CREDIT .JK 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 424 PHONE 425 NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 427 STATE UST FACILITY NUMBER(For Imal ue only) 428 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 Is 1998 Compliant?Y UPCF(1/99 revised)