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FIED PROGRAM CONSOLIDATED FORM O/ PIR#:PRO521942 FAC#:FA0014921 UNDERGROUND STORAGE TANKS - F�A7CILLI'jTY 77/JPIC)) �r eco pe -V oma. 2 36 I - L� / lone�g6 4 sP f B t TYPE OF ACTION ❑ 1.NEW SITE PERMIT ❑ 3.RENEWAL PERMIT Cl 5.CHANGE OF INFORMATION ❑ T PERMANENTLY CLOSED SITE ((Check one item only) ❑4.AMENDED PERMIT sp.*deave m.l use cely ± ❑ B.TANK REMOVED ❑6.TEMPORARY SITE CLOSURE 400 L FACILITY/SITE INFORMATION 1427 AIRPORT WAY,STOCKTON BUS IFIESSNAME(Sm�eas FAC[L NAME.DBA-Dome Bm&ca As) FACILITY ID# PR 1 RANCHO SAN MIGUEL MARKET" FAGO14921 PRO52t9az NEAREST CROSS STREET FACR.ITY OWNER TYPE ❑4.LOCAL AGENCY/DISTRICT' aol ® 1.CORPORATION ❑ 5.COUNTY AGENCY' BUSINESS S.COMMERCW. ❑2.INDMDUAL ❑ 6.STATE AGENCY' ❑ 1.GAS STATION ❑ 3.FARM ❑ ❑ 3.PARTNERSHIP 402 TYPE ❑ 2 DISTRIBUTOR ❑4.PROCESSOR ❑ 6.OTHER 403 ❑ 7.FEDERAL AGENCY' TOTAL NUMBER OF TANKS Is facility on IDdian ReurvRtion of 4ffowner of LIST is a public alyrncy:name of supervisor of division,section or office which operates REMAINING AT SITE truatlands? the LIST(This a the contact person for the tank records.) 4M ❑ Ya ® No 4°5 RANCHO SAN MIC INC °� II.PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407 PHONE OR NAHAL 1ASWANT S&SHARNJITK 09 MAR.ING OR STREET ADDRESS CITY 1386 TORRANCE AVE Oto 1 STATE all CODE 412 SUNNYVALE CA 94089 PROPERTY OWNER TYPE ❑ 1.CORPORATION ❑ 2.INDIVIDUAL ❑4.LOCAL AGENCY I DISTRICT ❑6.STATE AGENCY ®3.PARTNERSHIP El 5.COUNTY AGENCY El 7.FEDERAL AGENCY 411 III.TANK OWNER INFORMATION TANK OWNER NAME 414 PHONE 415 RANCHO SAN MIGUEL INC 209 957-2555 1; ING OR STREET ADDRESS 415 8014 LOWER SACRAMENTO RDZIP CO DE 414 CITY 411 STATE 411 STOCKTON CA 95205 TANK OWNER TYPE ❑ 1.CORPORATION ❑ 2.INDIVIDUAL 114.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY 420 ❑ 3.PARTNERSHIP ❑ 5.COUNTY AGENCY [:17.FEDERAL AGENCY IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY(TK)HQ 44- Call(916)322-9669 if questions Brise 421 V.PETROLEUM UST FINANCIAL RESPONSIBILITY INDICATE NIETHOD(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 422 El3.INSURANCE ❑6.EXEMPTION ❑ 9.STATE FUND&CD VI.LEGAL NOTIFICATION AND MAILING ADDRESS Check one box to indicate which address should be used for legal notifications and mailing. ❑ I.FACILITY 1912.PROPERTY OWNER ❑3.TANK OWNER 423 Legal notifications and mailing will be sent to the tank owner uvless box 1 or 2 is checked. VII.APPLICANT SIGNATURE Certification-I certify that the information provided herein is true and accurate to the best army knowledge. SIGNATURE OF APPLICANT DATE 424 PHONE 425 NAOF APPLICANT(print) 425 T117.E OF APPLICANT 423 ME STATE UST FACILITY NUMBER(F.local.mh) 428 1 1998 UPGRADE CERTIFICATE NUMEERIF.1.o1asemh) 429 Is 1998 Compliant? UPCF(1/99 revised)