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ev"D PROGRAM CONSOLIDATED Ff 9�G <br />TANKS <br />UNDERGROUND STORAGE TANKS - FACILITY <br />(one page per site) Page _ of <br />TYPE OF ACTION ® I. NEW SITE PERMIT ❑ 3. RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENTLY CLOSED SITE <br />(Check one item only) ❑ 4. AMENDED PERMIT specify change local use only ❑ 8. TANK REMOVED <br />❑ 6.TEMPORARY SITE CLOSURE 400 <br />L FACILITY / SITE INFORMATION (1 b f DD I <br />BUSINESS NAME (save as FACn.1TY NAME a »A - Doingllaeiness As) 3 <br />FACILITY IDM <br />1 <br />Stockton Gateway, L -t` r - <br />NEAREST CROSS STREET 3 2y ,5 , 401 <br />FACILITY OWNER 'TYPE ❑ 4. LOCAL AGENCY/DISTRICT• <br />East Lafayette (at South Center) C 4s� <br />® L CORPORATION ❑ 5. COUNTY AGENCY* <br />��..� <br />❑ 2. INDIVIDUAL ❑ 6. STATE AGENCY* <br />BUSINESS N 1. GAS STATION U 3. FARM Lj 5. COMMERCIAL <br />TYPE [12. DISTRIBUTOR [14. PROCESSOR ❑ 6. OTHER 403 <br />❑ 3. PARTNERSHIP ❑ 7. FEDERAL AGENCY* 402 <br />TOTAL NUMBER OF TANKS <br />Is facility on Indian Reservation or <br />•If owner of UST is a public agency_ nam of supervisor of division, section or office which <br />REMAINING AT SITE <br />trustlands? <br />operates the UST (This is the contact person for the tank records.) <br />3 404 <br />❑ Yes N No 405 <br />406 <br />11 PROPERTY OWNER INFORMATION <br />PROPERTY OWNER NAME 41P <br />PHONE 408 <br />Stockton Gateway LLC <br />209-466-3092 an Dixon <br />MAILING OR STREET ADDRESS 409 <br />345 South El Dorado Street <br />CITY 410 <br />STATE 411 <br />ZIP CODE 412 <br />Stockton I <br />CA <br />95203 <br />PROPERTY OWNER TYPE SLCORPORAITON ❑ 2. INDIVIDUAL [14. LOCAL AGENCY / DISTRICT ❑ 6. STATE AGENCY <br />❑ 3. PARTNERSHIP ❑ S. COUNTY AGENCY ❑ 7. FEDERAL AGENCY 413 <br />III. TANK OWNER INFORMATION <br />TANK OWNER NAME 414 <br />PHONE 415 <br />Stockton Gateway LLC <br />209-466-3092 (Lan Dixon) <br />MAILING OR STREET ADDRESS 416 <br />345 South El Dorado Street <br />CITY 417 <br />STATE 418 <br />ZIP CODE 419 <br />Stockton I <br />CA <br />95203 <br />TANK OWNER TYPE ® 1. CORPORATION ❑ 2. INDIVIDUAL ❑ 4. LOCAL AGENCY /DISTRICT ❑ 6. STATE AGENCY 420 <br />[13. PARTNERSHIP Q 5. COUNTY AGENCY Q 7. FEDERAL AGENCY <br />IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br />TY TK HQ 44- O Call 916 322-9669 ifquestions arise 421 <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br />INDICATE METHOD(s) ❑ 1. SELF-INSURED ❑ 4. SURETY BOND N 7. STATE FUND ❑ 10. LOCAL GOVT MECHANISM <br />❑ 2. GUARANTEE ❑ 5. LETTER OF CREDIT ❑ & STATE FUND & CFO LETTER ❑ 99. OTHER: <br />❑ 3. INSURANCE [16. EXEMPTION ❑ 9. STATE FUND & CD 422 <br />VL LEGAL NOTIFICATION AND MAILING ADDRESS <br />Check one box to indicate which address should be used for legal notifications and mailing. <br />Legal notifications and mailings will be sent to the tank owner unless box 1 or 2 is checked. ❑ 1. FACILITY ❑ 2. PROPERTY OWNER ® 3. TANK OWNER 421 <br />VII. APPLICANT SIGNATURE <br />Certifi -;,eerfiftflat the information provided herein is true and accurate to the best of my knowledge. <br />IGN <br />APPLICANT <br />DATE 424 <br />PHONE 425 <br />Co <br />916-372-0313 <br />NAME O P (print) 426 <br />TITLE OF APPLICANT 427 <br />Mike Lee <br />Architect <br />STATE UST FACILITY NUMBER (For local use ady) 428 <br />1998 UPGRADE CERTIFICATE NUMBER (Fm beat age Doty) 429 <br />UPCF (1/99 revised) 8 e, =e OV / 7 Z___ Formerly SWRCB Form A <br />rl <br />