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q <br /> f/121 d3 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (One page per site) Page L of <br /> TYPE OF ACTION [11.NEW PERMIT [13.RENEWAL PERMIT ❑5.CHANGE OF INFORMATION [17.PERMANENTLY CLOSED SITE 400' <br /> (Check one item only) ❑4.AMENDED PERMIT (Specify change) ❑S.TANK REMOVED <br /> 6,TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Sam.as FACILITY NAME or DBA-Doing Business;As) 3. FACILITY <br /> Rancho San Mi uel Market ID# 1. <br /> NEAREST CROSS STREET i 4Qq jY, AY 401, FACILITY OWNER TYPE ❑4.LOCAL AGENCY/DISTRICT* 402. <br /> ter Way StocktR[) 64K�J 'M2P.5 ®1.CORPORATION ❑5.COUNTY AGENCY* <br /> BUSINESS 9 1.GAS STATION Lj 3.FARM U 5.COMMERCIAL 403. ❑2.INDIVIDUAL ❑6.STATE AGENCY* <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR [-16.OTHER ❑3.PARTNERSHIP ❑7.FEDERAL AGENCY* <br /> TOTAL NUMBER OF TANKS 404. Is facility on Indian Reservation 405. *If owner of UST is a public agency:name of supervisor of division,section or 406. <br /> REMAINING AT SITE or trust lands? office which operates the UST. (This is the contact person for the took records.) <br /> r5[ <br /> ❑Yes 11N0 <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 401. <br /> Rancho San Miguel Inc. 209-957-2555 <br /> MAILING OR STREET ADDRESS 409. <br /> 814 Lower Sacramento Rd <br /> CITY 610- STATE 411. ZIP CODE 412. <br /> Stockton CA 95205 <br /> PROPERTY OWNER TYPE L39 I.CORPORAUON ❑2.INDIVIDUAL [14.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 411. <br /> [-13.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> III.TANK OWNER INFORMATION <br /> TANKOWNERNAME 414, PHONE 415, <br /> Rancho San Miguel Market 209-957-2555 <br /> MAILING OR STREET ADDRESS 416' <br /> 814 Lower Sacramento Rd <br /> CITY 4n. I STATE 418. ZIP CODE 419. <br /> Stockton CA 95205 <br /> TANK OWNER TYPE La I.CORPORATION ❑2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 420. <br /> 3.PARTNERSHIP 5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY TK HQ 44- 1 1 1 1 1 1 1 Call 916 322-9669 if questions arise 421. <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ❑1.SELF-INSURED [14.SURETY BOND 7.STATE FUND [110.LOCAL GOVT MECHANISM 4u <br /> ❑2.GUARANTEE Ll 5.5.LETTER OF CREDIT 8.STATE FUND&CFO LETTER ❑99.OTHER: <br /> 3.INSURANCE ❑6.EXEMPTION [19.STATE FUND&CD <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one box to 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. ❑ 1.FACILITY [R2. PROPERTY OWNER [13.TANK OWNER 423. <br /> VII.APPLICANT SIGNATURE <br /> Certification: 1 cthat the information provided herein is true and accurate m the best of my knowledge. <br /> SIGNATURE APELICANT DATE 424, PHONE 425. <br /> 7/17/03 209-957-2555 <br /> NAME OF APPLICANT(print) 426. TITLE OF APPLICANT 427. <br /> Dennis Cove Director <br /> STATE UST FACILITY NUMBER(Agency use only) 421. 1998 UPGRADE CERTIFICATE NUMBER(Agency use only) 429. <br /> (See Data Element I,above. <br /> UPCF Hwfwrc-a(1/99)-12 htip://www.unidoes.org Rtw.02/16/00 <br />