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1 <br /> IFIED PROGRAM CONSOLIDATED FORNO L/ I K y'l <br /> 9 12 <br /> UNDERGROUND STORAGE TANKS -FACILITY <br /> rte, <br /> (one page per site) <br /> TYPE OF ACTION ❑ 1.NEW SITE PERMIT ❑ 3.RENEWAL PERMIT 5.CHANGE OF INFORMATION ❑ 7.PERMANENTLY CLOSED>fE <br /> (Check one item only) ❑ 4.AMENDED PERMIT ❑ 8.TANK REMOV <br /> ❑6.TEMPORARY SITE CLOSURE / /fl 400:. <br /> I.FACILITY/SITE INFORMATION 147 E LATHROP RD,LATHROP #A ' <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 FACILITY ID# I PR ID# Lp <br /> TWO GUYS FOOD&FUEL** FA0003789 PRO232353 T I I ` <br /> NEAREST CROSS STREET FACILITY OWNER TYPE <br /> LATHROP 40l ❑ 4.LOCAL AGENCY/DISTRICT• <br /> ❑ I.CO ORATION ❑ 5.COUNTY AGENCY' <br /> BUSINESS INDIVIDUAL <br /> E] 1.GAS STATION ❑ 3.FARM ® 5.COMMERCIAL E] 6.STATE AGENCY* <br /> TYPE <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 *If owner of UST is a public agency:name of supervisor of division,section or office which operates <br /> REMAINING AT SITE trusdands? the UST This is the contact <br /> ( person for the tank records.) <br /> 404 ElYes El No 405 406 <br /> II.P OPERTY OWNER INFORMATION <br /> C <br /> PROPERTY OWNER NAME 44T HONE 408 <br /> 209' 239-4141 <br /> MAILING OR STREET ADDRESS 409 <br /> PO BOX 1022 <br /> CITY 410 STATE 411 ZIP CODE 412 <br /> MANTECA 4 CA 1 95336 <br /> PROPERTY OWNER TYPE 1s ).CORPORATION .INDIVIDUAL El4.LOCAL AGENCY/DISTRICT El6.STATE AGENCY <br /> ❑3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY 413 <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> CARDOZA ED&DOLORES 209 239-4141 <br /> MAILING OR STREET ADDRESS 416 <br /> PO BOX 1022 <br /> CITY 417 STATE 418 ZIP CODE 419 <br /> MANTECA CA 95336 <br /> TANK OWNER TYPE #PI.CORPORATION 2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT 1:16.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- 44-024690 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 137.STATE FUND El10.LOCAL GOVT MECHANISM <br /> El2.GUARANTEE ❑5.LETTER OF CREDIT IH 8.STATE FUND&CFO LETTER X❑99.OTHER <br /> El 3.INSURANCE El 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. .41 1.FACILITY2.PROPERTY OWNER El 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 /> SIGN ANT DA .J�-� aza P�NE 425 <br /> Z1� _4�4 <br /> NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 427 <br /> STATE UST FACILITY NUMBER(For local ue only) 428 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 <br /> Is 1998 Compliant?Y <br /> UPCF(1/99 revised) <br />