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0 IED PROGRAM CONSOLIDATED FORM PR#:PR0504388 r FAC#:FA0006185 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 1605 S ELDORADO ST,STOCKTON BUSINESS NAME(Samc as FACILITY NAME or DBA-Doing Business As) 3 FACILITY ID# PR ID# E-Z STOP MINI MART On t et M FA0006185 PR0504388 1 NEAREST CROSS STREET ! E7 �C FACILITY OWNER TYPE ❑4.LOCAL AGENCY/DISTRICT' EL DORADO I L j L_b C/��A� S+r aoi ❑ 1•SORPORATION ❑ 5.COUNTY AGENCY' BUSINESS ® 1.GAS STATIO 3.FARM 5.COMMERCIAL 2.INDIVIDUAL ❑ 6.STATE AGENCY* TYPE ❑ 3.PARTNERSHIP 402 ❑ 2.DISTRIBUTOR ❑ 4.PROCESSOR ❑ 6.OTHER 413 ❑ 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 ® No 405 Al A 406 II.PROPERTY OWNER INFORMATION PROPERTY OWNER NAME L_ y _ - 407 PHONE 408 E Z STOP MINI MART �� ' 209 939-1906 MAILING OR STREET ADDRESS -C �- 409 5515 TAMARINDO LN S 60 Nd v A-VV '�--d`�'tN C ( _L_(o N ( ~ CITY 410 STATE 411 ZIP CODE 412 phitiffRovr- fi=fZC�m� N� CA -^ a4�`3 � 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 OWN NAME _ 414 PHONE (p '�!��- Zi 5415 E Z ST MINI MART NI L- � FT-TsU V - MAILING OR STT ADDRESS �(O 7-tug-7- 4 5515 TAMA DO LN I eq 0(" CITY 411 STATE 418ZIP COD 41 ELK GROVE CA 195758Z)AL- W- - tO l- TANK OWNER TYPE ❑X 1.CORPORATION ❑ 2.INDIVIDUAL ❑ 4.LOCAL AGENCY/DISTRICT6❑� STATE AGENCY 420 ❑ 3.PARTNERSHIP ❑ 5.COUNTY AGENCY 1:17.FEDERAL AGENCY IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY - 44-000 L AJ � (3 l= NO i( ffE-b Call(916)322-9669 if questions arise 421 S 0.0 iti Pf-S ETROLEUM UST FINANCIAL RESPONSIBILITY INDICATE METHOD(s) 1:11.SELF-INSURED E] D 4.SURETY BOND - STATE FUND ❑ 10.LOCAL GOVT MECHANISM ❑2.GUARANTEE ❑5.LETTER OF CREDIT ❑ 8.STATE FUND&CFO LETTER 0 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 I or 2 is checked. VII.APPLICANT SIGNATURE Certification-I certify that the' tion provided herein is true and accurate to the best of my knowledge. SIGNATURE OF APPLIC T, DATE 424 PHONE 425 NAME OF APPLIC 426 TITLE OF APPLICANT 427 STATE UST FACILITY NUMBER(For total ue only) 428 1998 UPGRADE CERTIFICATE NUMBER(For 1.1 use only) 429 Is 1998 Compliant?Y UPCF(1/99 revised)