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NJ PIED PRM;RAM CONSOLIDATED FOR PR#:PRO231580 <br /> \u FAC#:FA0007963 <br /> UNDERGROUND STORAGE TANKS-FACILITY <br /> (one page per site) <br /> TYPE OF <br /> TIION ❑ 1 NEW Srrs PERMR ❑7.RENEWAL PERMIT ij} S CHANGE OF INFORMATION ❑7.PERMANENTLY CLOSED SIT, <br /> ❑4.AMENDEDPERMIT jpmfyduegeih'eo - ❑ S.TANK REMOVED <br /> U <br /> ❑6.TEMPORARY SITE CLOSURE <br /> I.FACILITY/SITE INFORMATION 2420 W GRANT LINE RD,TRACY <br /> BUSINESS NAME(Sm MPAce.lT Bw DBA-Driq Bm.M) a FACILITYID# PR II# <br /> GRANT LINE VALERO FA0003963 PRO231590 <br /> NEAREST CROSS STREET FACILITY OWNER TYPE <br /> GRANT LINE Mt b'LCORPORATION ❑5.COUNTYACAL AGENCY- <br /> BUSINESS <br /> BUSINESS ❑s.cooN7v Aa�NCY• <br /> TYPE I.GAS STATION ❑3.FARM 5.COMMERCIAL ❑2.INDMDUAL ❑6.SPATE AGENCY" <br /> ❑2.DISTRIBUTOR ❑ 4.PROCESSOR ❑6.0THER 4m ❑ I PARTNERSHIP ❑7 FEDERAL AGENCY• 402 <br /> TOTAL NUMBER OF TANKS B facility on Indian Reserva(ian or •IfownmofllST sea blica enc colza <br /> TOTAINUMBERING AT SITE trtuBaMs7 pu g ytmm W>iwrofdivi.im.section or office which operates <br /> REMN.UST(Thi.tithe contact penon for the tmk mcordz.) <br /> aw ❑Yes lO No 40 40 <br /> IL PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER N ^. - •aW PHONE -0 m <br /> b372- 4 <br /> T cTF..FAR[YI -INC, 'CATkd. _L <br /> OR 57R7cT D <br /> zyz - re <br /> T(� �� 410 STATE _ aH ZIP CODE 41z <br /> `J, 537ffi <br /> PRO Y0 TYPE 0 CORPORATION X2.INDrVmUAL 04.LOCAL AGENCY/DISTRICT El 6.STATE AGENCY <br /> ❑3.PARTNERSUP 115.COUNTY AGENCY 117.FEDERAL AGENCY 413 <br /> III.TANK OWNER INFORMATION <br /> TANKOW4ERNAME414PHONE 20 -y32- 8213 415 <br /> TO�EST FAR <br /> INC �. �r4t (a'S 9C PCS oy txf <br /> MAILING OR STREET ADDRESS <br /> 416 <br /> •2499-TesxE-RD RD <br /> CITY 417 ATE tie 1 ZIPCODE 41% <br /> TRACY CA 95376 <br /> TANK OWNER TYPE 1CORPORATION2.INDIVIDUAL 1:14.LOCAL AGENCY/DISTRICT 13 6.STATE AGENCY 420 <br /> ❑3.PARTNERSHIP ❑ S.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- `4471- Call(916)322-9669 if questions arise 021 <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(,) ❑ 1.SELF-INSURED ❑A SURETY BOND 7.STATE FUND 10.LOCAL GOVT MECHANISM <br /> EI 2.GUARANTEE ❑5.LETTER OFCREDrr � ❑&STATE FUND&CFO LETTER M 99.OTHER <br /> ❑3.INSURANCE 116.EXEMPTION ❑ 9.STATE FUND&CD 422 <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Chest one box to indicate which acidosis should be mad for le lmtifeatiom and mailing. ® IFACBIfY ❑2.PROPERTY OWNER ❑3.TANKOWNER m <br /> Legal notifications and mailing will be sent to ilia conk owner unless box I or 2 is chcckM. <br /> VIL APPLICANT SIGNATURE <br /> Cenifintioa 1 certify that the infomwtion provided herein citrus and acc nate to the best ofmy knowledge. <br /> SIGNATURE OF APPLICANT DATE .2a PHONE 425 <br /> V, ite2o Tz- 72 <br /> NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 417 <br /> STATE UST FACILITY NUMBER(Fwlml is coy) 428 1998 UPGRAI)k 15ERTIFICATH NUMBER(Porbul weedy) us <br /> Is 1998 Compliant?Y <br /> UPCF(1/99 revised) <br />