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03 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (One page per site) Page L Ofi- <br /> TYPE OF ACTION ❑I,NEW PERMIT ❑3.RENEWAL,PERMIT ❑5.CHANGE'Of INFORMATION ❑7.PE"ANENTLY CLOSED SITE <br /> Inn <br /> 4,AMENDED PERMIT (Specify change) ❑&TANK tt1iMOVI:D <br /> (Check one item only) ❑❑6,TEMPORARY SITE CLOSURE' <br /> 1. FACILITY/SITE INFORMATION <br /> ItIP�INI'.SSNAME.Is me nsrnCII,IrvNAM17r 1)A-Do„t;n,,s acssM 3 FAC11LITY y <br /> u Jaa <br /> Honcho Sall Miguel MarketIT <br /> NI;AEtIiS'I'CROSS STRI FT, out FACILI"I'Y OWNER TYPE 4.LOCAL.AGFNCY1DIS'I'ItIC'C* 4uz <br /> O on ® I.CORPORA'L'ION ❑5.COUNTY AOIiNCY* <br /> 91115-1,2,0 Charter. W BUSINESS Ij I.GAS STATION 3.FARM ❑5,COMMERCIAL 4tu ❑2.1NDIVIDUAI, ❑6.STATE AGENCY* <br /> l'YPE El 2.DISTRIBUTOR ❑4.PROCESSOR ❑6,OTI LI R [13.PARTNI:RSl 111' ❑7.FEDERAL AGENCY* <br /> 409, *Ir owner or UST is a pulelic agcttcy: name or supervisor of division, section or 406. <br /> '1'EMAI NUMBER OF YANKS 4141 Is facility on Indian Reservation office which operates the UST. (This is the contact person for the tank records.) <br /> REMAINING AT SITE Or trust lands? <br /> ❑Yes [3NO <br /> 11. PROPERTY OWNER INFORMATION <br /> PROPER"rY OWNER NAME; 4a7 I*I{ONE anx. <br /> Rancho San Miguel Inc. 209-957-2555 <br /> 409. <br /> MAILING OR STREE-r ADDRESS <br /> 814 Lower Sacramento Rd 411) 411. ZIPCODE 412. <br /> CITYSTATE <br /> Stockton CA 95205 <br /> PROPERTY OWNER TYPE 1.CORPORATION 2.INDIVIDUAL ❑4.LOCAL AG[:NCY 1 DIS'I'RIC'r ❑b.STATE AGE CY <br /> a9J <br /> ❑3.PARTNERS111P ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME <br /> aroa. I'IIONI a19. <br /> (Rancho San Miguel Market 209-957-2555 <br /> alr. <br /> MAILING OR STREET ADDRESS <br /> 814 Lower Sacramento Rd 417 S'f'A"rE; 41x. LII'CODE al <br /> CITY <br /> E <br /> Stockton CA 95205 <br /> TANK OWNE:R'I'YPE 1.CORPORATION ❑2.INDIVIDUAL ❑4.LOCAL AGENCYIDIS'1RICT ❑6.STATE AGENCY 420. <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FCDERAL AGENCY <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY TK 1 IQ 44- <br /> Call 915 322-9669 i!' uestiuns arise 421. <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METIIOD(s) <br /> I.SELF-INSURED ❑4,SURETY.11OND 7.STATE FOND ❑10.LOCAL H"I'MIIANISM 427 <br /> [:12.GUARANTCL ❑5,LETTER OF CREDIT S.STATE FUND i&CFO LETTER ❑`l`1.OT1[LR: <br /> ❑3.INSURANCE ❑G.EXEMPTION ❑9.STATE FUND&CD <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one box to indicate which address should be used far legal notificatiars and tnailiug. [X2. PROPERTY OWNER ❑3.TANK JN2,1 <br /> Legal notifications and mailings will be sent to the tank owner unless box I or 2 is checked. ❑ 1.FACILITY <br /> VII.APPLICANT SIGNATURE <br /> ggQ;;; <br /> c that.the information provided herein is true and accurate to the best of my knowledge.DATE: 424.Al 'LICANT209-957-257117103 <br /> PPLICANT(print) 426, TITLE OPAPPLICANT <br /> s Cave DirectorFACILITY NUMBER(Agencywe only? 42x 1998 UPGRADE CER('I'ICATENUMBER(Ar,„-yuwwy) 421)' <br /> tnent I,above. <br /> http://ivww.unidoes.org Rev.02/16100 <br /> UPCF ilrvfwrc-a(1199)-112 p' <br />