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�FIED PROGRAM CONSOLIDATED FORM / �^ PR#:PRO506545 / 1 2 FAC#:FA0007491 ��ti UNDERGROUND STORAGE TANKS -F t oNoe ,�/0 3 5A01 (one page per site) 3 TYPE OF ACTION ❑ L NEW SITE PERMIT ❑3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENTLY CLOSED SITE (Check one item only) ❑ 4.AMENDED PERMIT specify change local use only ❑ 8.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) g FACILITY ID# 1 PR ID# COUNTRY MARKETPLACE TRUCK WASH FA0007491 PRO506545 1 NEAREST CROSS STREET 1 tc 2_f j1 FW 401 FACILITY OWNER TYPE E:14.LOCAL AGENCY/DISTRICT- FRESNO - ❑ 1.CORPORATION ❑ 5.COUNTY AGENCY" BUSINESS ® 1.GAS STATION ❑ 3.FARM ❑ 5.COMMERCIAL [1 2.INDIVIDUAL ❑ 6.STATE AGENCY' TYPE E] 2. 3.PARTNERSHIP 40' 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 405 406 11.PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407 PHONE 408 SUKHBINDAR S GILL 408 741-5451 MAILING OR STREET ADDRESS 409 16990 MCGILL RD CITY 410 1 STATE 411 ZIP CODE 412 SARAGOGA CA 95070 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 OWNER NAME 414 PHONE 415 COUNTRY MARKETPLACE 209 933-1789 MAILING OR STREET ADDRESS 416 1789 W CHARTER WY CITY 417 1 STATE 418 ZIP CODE 419 STOCKTON CA 195206 TANK OWNER TYPE ❑ 1.CORPORATION ❑ 2.INDIVIDUAL ❑ 4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY 420 ❑ 3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY(TK)HQ 44- 44-038743 1 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 ❑5.LETTER OF CREDIT ❑ 8.STATE FUND&CFO LETTER ❑99.OTHER X❑3.INSURANCE ❑6.EXEMPTION ❑ 9.STATE FUND&CD a" 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 415 NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 427 STATE UST FACILITY NUMBER(For local ue only) 428 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 Is 1998 Compliant?Y UPCF(1/99 revised)