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UNIFIF,D PROGRAM CONSOLIDATED FORM! n <br /> j 9� TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY a I <br /> (one page per site) Page_of_ <br /> TYPE OF ACTION ❑ 1.NEW SITE PERMIT 0 3.RENEWAL PERMIT [IS.CHANGE OF INFORMATION [:] 7.PERMANENTLY CLOSED SITE <br /> (Check one item only) [14.AMENDED PERMIT specify change IoW use only ❑ S.TANK REMOVED <br /> ❑6.TEMFoRARY SITE CLOSURE 400 <br /> I. FACILITY/SITE INFORMATION <br /> BUSINESS NAME(S.as FACILITY NAME orFACILITY 1D <br /> My Mini Mart DBA-Dome Busmen N) 3 <br /> NEAREST CROSS STREET 401 FACILITY OWNER TYPE L j 4.LOCAL AGENCY/DISTRICT' <br /> Bradford ❑ 1.CORPORATION ❑5.COUNTY AGENCY' <br /> BUSINESS 1.GAS STATION 3.FARM Lj 5. COMMERCIAL ® 2.INDIVIDUAL ❑6.STATE AGENCY' <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR❑6. OTHER 4o3 ❑ 3.PARTNERSHIP ❑7.FEDERAL AGENCY' 402 <br /> TOTAL NUMB ER OF TANKS Is facility on Indian Reservation or *If owner of UST is;public agency:name of supervisor of division,section or office which <br /> REMAINING AT SITE trustlands7 operates the UST(This is the contact person for the tank records.) <br /> 2 404 ❑ Yes I& No 403 406 <br /> 11. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 40a <br /> Jo finder Lal (209) 941-2264 <br /> MAILING OR STREET ADDRESS 409 <br /> 1756 N. Wilson Way <br /> CITY 410 STATE all ZIP CODE 412 <br /> Stockton CA 95205 <br /> PROPERTY OWNER TYPE 1.CORPORATION Z12.INDIVIDUAL U 4.LOCAL AGENCY/DISTRICT LJ6.STATEAGENCY <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY 413 <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE a3 <br /> Joginder Lal (209) 941-2264 <br /> MAILING OR STREET ADDRESS 416 <br /> 1756 N. Wilson Way <br /> CITY n7 STATE 419 ZIP CODEu9 <br /> Stockton CA 95205 <br /> TANK OWNER TYPE 1.CORPORATION V9 2.INDIVIDUAL U 4.LOCAL AGENCY/DISTRICT 06.STATEAGENCY 426 <br /> ❑3.PARTNERSHIP [IS.COUNTY AGENCY [17.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY TK HQ 44- 1 1 1 1 1 Call 916 322-9669 if questions arise 421 <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ❑L SELF-INSURED ❑4.SURETY BOND [17.STATE FUND [110.LOCAL GOVT MECHANISM <br /> [12.GUARANTEE ❑5.LETTER OF CREDIT ISI S.STATE FUND&CFO LETTER ❑ 99.OTHER: <br /> ❑3.INSURANCE ❑6.EXEMPTION [19.STATE FUND&CD 422 <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one box te 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 I or 2 is checked. ❑ L FACILITY El 2. PROPERTY OWNER ❑3.TANK OWNER 4M <br /> VII.APPLICANT SIGNATURE <br /> Certification-I certify that the information provided herein is true and accurate to the but of my knowledge. <br /> SINATURE OF APPLICANT DATE 424 PHONE 425 <br /> yD (209) 941-2264 <br /> NAME OF APPLICANT(print) 436 TITLE OF APPLICANT 427 <br /> Joginder Lal Owner <br /> STATE UST FACILITY NUMBER(For mal wo only) 428 1999 UPGRADE CERTIFICATE NUMBER(For ioal we only) 429 <br /> UPCF(1/99 revised) 8 Formerly SWRCB Form A <br />