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IFIED PROGRAM CONSOLIDATED FOR //n /J /�-7 PR#:FA014921 tCX r /y FPR0521942 AC#: UNDERGROUND STORAGE TANKS - FACILITY (one page per site) TYPE OF ACTION ❑ I.NEW SITE PERMIT ❑ 3.RENEWAL PERMITS.CHANGE OF INFORMATION E:17.PERMANENTLY CLOSED SITE (Check one item only) ElC AMENDED PERMIT ❑ 8.TANK REMOVED ❑6.TEMPORARY SITE CLOSURE 400 1.FACILITY/SITE INFORMATION 1427 AIRPORT WAY,STOCKTON BUSINESS NAME(S.as FACILDY NAME or DBA-D ,ressse As) 9 FACILITY ID# I PR ID# RANCHO SAN MIGUEL MARKET* FA0014921 PR0621942 NEAREST CROSS STREET FACILITY OWNER TYPE ❑4.LOCAL AGENCY/DISTRICT- 401 ® L CORPORATION ❑ 5.COUNTY AGENCY' BUSINESS ❑ I GAS STATION ❑ 3.FARM ❑ 5.COMMERCIAL ❑ 2.INDIVIDUAL ❑ 6.STATE AGENCY' TYPE ❑ 2 DISTRIBUTOR ❑4.PROCESSOR ❑ 6.OTHER 403 ❑ 3.PARTNERSHIP ❑ 7.FEDERAL AGENCY' 401 TOTAL NUMBER OF TANKS Is facility on Indian Reservation or 'Ifowner of UST is a public agency.name of supervisor ofdivisioR section or office which operates REMAINING AT SITE trustlands? the UST(Thu is the contact person for the tank records.) 4a ❑ Yes 8 No 409 RANCHO SAN MIGUEL INC w6 II.PROPERTY OWNER INFORMATION PROPERTY OWNER NAME11 PHONE 408 .rnran oA*r�arnrrna-rirn N1- AHAC 3gsW4� S S'n Ar_0j MAILING OR STREET ADDRESS .. ., 1 409 -set4-nnr V R sxcmmm 7mD 13 B 6 To rr q I)e-- Q vc . CITY 410 STATE 411 ZIP CODE 411 PROPERTY OWNER TYPE ❑ ) CORPORATION ❑ 2.INDIVIDUAL ❑ 4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY 413 III.TANK OWNER INFORMATION TANK OWNER NAME 414 PHONE 415 RANCHO SAN MIGUEL INC 209 957-2555 MAILING OR STREET ADDRESS 416 8014 LOWER SACRAMENTO RD CITY m7 STATE 419 ZIP CODE 419 STOCKTON CA 95205 TANKOWNERTYPE ❑ 1.CORPORATION El 2.INDIVIDUAL El 4.LOCAL AGENCY/DISTRICT El 6.STATE AGENCY 010 ❑ 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 arise 431 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 ❑ S.STATE FUND&CFO LEITER 19199.OTHER ❑3.INSURANCE Cl 6.EKEmpT10N ❑ 9.STATE FUND&CD 422 VI.LEGAL NOTIFICATION AND MAILING ADDRESS Check one box to indicate which address shoWd be used for legal notlfications and mailing. ❑ 1.FACILITY X2.PROPERTY OWNER X3.TANK OWNER 413 Legal notifications and mailing will be sent to the tank owner unless box I or 2 is checked. \ VII.APPLICANT SIGNATURE Cenifi a[ 'y that n provided heroin is hostand accurate to the best ofmy knowledge. SIGN F P DATE 41 PHONE 425 C-/3-vim NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 423 STATE UST FACILITY NUMBER(For heal mcon) 429 1998 UPGRADE CERTIFICATE NIMBER(Fooccel ma rely) 42Y Is 1998 Compliant? UPCF(1/99 revised)