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` IED PROGRAM CONSOLIDATED FORM PR#:PR0506545 t� FAC#:FA0007491 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) E]4.AMENDED PERMIT sped Cy change local use only ❑ g,TANK REMOVED [-]6.TEMPORARY SITE CLOSURE 400 I.FACILITY/SITE INFORMATION 1524 FRESNO AVE,STOCKTON BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 FACILITY 1D# PR ID# COUNTRY MARKETPLACE TRUCK WASH FA0007491 PR05o6sa5 NEAREST CROSS STREET FACILITY OWNER TYPE FRESNO 401 El 1.CORPORATION ❑ 4.LOCAL AGENCY/DISTRICT* BUSINESS El 5.COUNTY AGENCY* ❑ L GAS STATION ❑ 3.FARM El 5.COMMERCIAL ❑ 2.INDIVIDUAL [j 6.STATE AGENCY* TYPE ❑ 2.DISTRIBUTOR ❑ 4.PROCESSOR ❑ 6.OTHER 403 ❑ 3.PARTNERSHIP ❑ 7.FEDERAL AGENCY* 402 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 405 406 II.PROPERTY OWNER INFORMATION PROPERTY OWNER NAME407 PHONE-2 D 9 8-70-36'D,r 408 arR 'l ahU 1 MAILING OR STREET ADDRESS 409 1789 4) C r-Ee,r W CITY 410 STATE all ZIP CODE 412 - 66- :5+00'K o h CA PROPERTY OWNER TYPE `fl 1.CORPORATION ❑ 2.INDIVIDUAL El4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY ❑3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY 413 III.TANK OWNER INFORMATION TANK OWNER NAME 414 PHONE Q0 -*74p-35-09' 415 M.2 r MAILING OR STREET ADDRESS 416 1789 W CHARTER WY CITY 417 STATE 74,, Z]iP- CODE 419 STOCKTON CA 5206 TANK OWNER TYPE 1.CORPORATION ❑ 2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY 420 ❑ 3.PARTNERSHIP 1:15.COUNTY AGENCY ❑ 7.FEDERAL AGENCY IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY(TK)HQ 44- 44-A3$9+43* 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 1:15.LETTER OF CREDIT ❑ 8.STATE FUND&CFO LETTER 1:199.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 information provided herein is true and accurate to the best of my knowledge. SIGN OF APPLIC T DATE 424 PHONE 425 AME OF APPLICANT(print) 426 TITLE OF APPLICANT 427 T L S - - STATE UST FACILITY NUMBER(For local ue only) 428 1998 UPGRADE CER CATE NUMBER(Por local use only) 429 Is 1998 Compliant?Y UPCF(1/99 revised)