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I V-7 kie 4e4 IFIED PROGRAM CONSOLIDATED FORM* .2 /<2�Z.'t1S7?eR ZL FAC#:FA0014678 UNDERGROUND STORAGE TANKS - FACILITY( ( j J Gt)�(U� (one page per site) TYPE OF ACTION ❑ I.NEW SITE PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ Z PERMANENTLY CLOSED SITE (Check one item only) ❑ 4.AMENDED PERMIT slxci6eAeesebmlmeooly ❑ B.TANK REMOVED ❑6.TEMPORARY SITE CLOSURE I.FACILITY/SITE INFORMATION 713 N EL DORADO ST.STOCKTON BUSINESS NAME(Ssme as FACILITY NAME ar DBA-Dans Boeumss As) 3 FACII-TTY ID# PR ID# 1 CURRYS GAS FA0014678 PRO521604 NEAREST CROSS STREET 4eI FACILITY OWNER TYPE ❑4.LOCAL AGENCY/DISTRICT' ® 1.CORPORATION ❑ 5.COUNTY AGENCY' BUSBVESS ® ❑2.INDIVIDUAL 1.GAS STATION ❑3.FARM ❑ 5.COMMERCIAL [16.STATE AGENCY' a02 TYPE ❑ 2.DISTRIBUTOR ❑4.PROCESSOR ❑ 6.OTHER 403 ❑ 3.PARTNERSHIP ❑ 7,FEDERAL AGENCY' TOTAL NUMBER OF TANKS Is facility on Indian Reservation or 'If owner of is a public agency:name of supervisor ofdivisiom section m office which operates REMAINING AT SITE trustlands? the UST(This is the contact person for the tank records.) 404 ❑ Yes M No 405 406 II.PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407 PHONE 408 CHANDLE WILEY 209 298-7505 MAILING OR STREET ADDRESS 409 PO BOX 507 CITY 410 1 STATE 411 ZIBCODE 412 STOCKTON CA 1 5201 PROPERTY OWNER TYPE ❑ ICORpORATION M2.INDIVIDUAL ❑ 4.LOCAL AGENCY/DISTRICT El 6.STATE AGENCY ❑3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY 413 I1I.TANK OWNER INFORMATION TANK OWNER NAME 414 PHONE 415 CHANDLER INTERNATIONAL LLC 209 298-7505 MAILING OR STREET ADDRESS 416 PO BOX 507 CITY 417 STATE 418 ZIP CODE 419 STOCKTON CA 95201 TANK OWNER TYPE ® 1,CORPORATION [3 2.INDIVIDUAL El 4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY 420 [-13.PARTNERSHIP [15.COUNTY AGENCY ❑ 7.FEDERAL AGENCY IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY(TIC)HQ 44- Call(916)322-9669 if questions arise 421 V.PETROLEUM UST FINANCIAL RESPONSIBILITY INDICATE METHOD(s) ❑ 1.SELF-INSURED 114.SURETY BOND ❑ 7.STATE FUND ❑ I0.LOCAL GOVT MECHANISM ❑2.GUARANTEE ❑5.LETTER OF CREDFC D S.STATE FUND&CFO LETTER ❑99.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. ❑ I FACILITY ®2,PROPERTY OWNER ❑3.TANK OWNER 423 Legal notifications and mailing will be sent to the link owner unless box 1 or 2 is checked. VII.APPLICANT SIGNATURE Certification-1 certify dua the information provided herein is true and accurate to the best of my knowledge. SIGNATURE OF APPLICANT DATE 424 PHONE szs (209)298-7505 NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 4n CHANDLER INTERNATIONAL LLC OWNER STATE UST FACILITY NUMBER(Forlowucony) 428 1998 UPGRADE CERTIFICATE NUMBER(ForlonlusetatO 4'-0 Is 1998 Compliant? UPCF(1/99 revised)