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'IED PROGRAM CONSOLIDATED FORN PR#:PR4231118 FAC 1:EM003284 UNDERGROUND STORAGE TANKS -FACILITY V6(;A 6('Pl_�� (one page per site) l TYPE OF ACTION ❑ 1.NEW SITE PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENTLY CLOSED SITE (Check one item only) ❑ 4.AMENDED PERMIT ❑ 8.TANK REMOVED ❑6.TEMPORARY SITE CLOSURE 400 I.FACILITY/SITE INFORMATION 2185 E FREMONT ST.STOCKTON BUSINESS NAME(Same as FACIL NAME or DB -Do' ess As) 3 FACILITY ID# PR ID# ASOLINE FA0003284 PR0231118 NEAREST CROSS STREET FACILITY OWNER TYPE aol ❑4.LOCAL AGENCY/DISTRICr' FREMONT ® 1.CORPORATION ❑ 5.COUNTY AGENCY" BUSINESS ❑2.INDIVIDUAL ® 1•GAS STATION ❑ 3.FARM ❑ 5.COMMERCIAL ❑6.STATE AGENCY' TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR ❑ 6.OTHER 403 ❑ 3.PARTNERSHIP ❑ 7.FEDERAL AGENCY* 402 TOTAL NUMBER OF TANKS Is facility on Indian Reservation or 'If owner of UST is a public agency:name of supervisor of division,section or office which operates REMAINING AT SITE tntstlands? the UST(This is the contact person for the tank records.) 404 ❑ Yes ® No 405 406 H.PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 40� PHONE 408 LAL JOGINDER 209 941-2264 MAILING OR STREET ADDRESS 409 1756 N WILSON WAY CITY alo STATE 411 ZIP CODE 412 STOCKTON CA 95205 PROPERTY OWNER TYPE ® 1.CORPORATION ❑ 2.INDIVIDUAL ❑ 4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY ❑3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY 413 III.TANK OWNER INFORMATION TANK OWNER NAME 414 PHONE als LAL JOGINDER 209 941-2264 MAILING OR STREET ADDRESS 416 1756 N WILSON WAY CITY 417 STATE 418 ZIP CODE 419 STOCKTON CA 195205 TANK OWNER TYPE ❑ 1.CORPORATION ❑ 2.INDIVIDUAL ❑ 4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY 420 ❑ 3.PARTNERSHIP 115.COUNTY AGENCY ❑ 7.FEDERAL AGENCY IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY(TK)HQ 44- 44-032226 Call(916)322-9669 if questions arise 411 V.PETROLEUM UST FINANCIAL RESPONSIBILITY INDICATE METHOD(s) p 1.SELF-INSURED 1:14.SURETY BOND ❑ 7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM 1:12.GUARANTEE 1:15.LETTER OF CREDIT ❑ 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. ® 1.FACILITY ❑2.PROPERTY OWNER ❑3.TANK OWNER 423 Legal notifications and mailing will be sent to the tank owner unless box I or 2 is checked. VII.APPLICANT SIGNATURE Certification-I certify that the information provided herein is true and accurate to the best of my knowledge. SIGNATURE OF APPLICANT DATE 4z4 PHONE �O 425 � 7 NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 427 STATE UST FACILITY NUMBER(For local ue onk) 428 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 Is 1998 Compliant? UPCF(1/99 revised)