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'IED PROGRAM CONSOLIDATED FORA PR#:PRO231118 • FAC#:FA0003284 UNDERGROUND STORAGE TANKS - FACILITY K� i1n o (one page per site) 6\ TYPE OF ACTION ❑ I.NEW SITE PERMIT ❑ 3.RENEWAL PERMIT ❑ 5 ('FLANGE OF INFORMATION ❑ 7.PERMANENTLY CLOSED SITE (Check one item only) ❑ 4.AMENDED PERMIT spzc fycluny ❑ S.TANK REMOVED i �la�al use onPo 6 l-EMPORARY SITE CLOSURE 400 I.FACILITY/SITE INFORMATION 2185 E FREMONT ST.STOCKTON BUSINESS NAME(Same as FACILAX NAME or DB&-DoLwfiiisinm As) 3 FACILITY IDI I PR ID# ASOLINE FA0003284 PR0231118 1 NEAREST CROSS STREET FACILITY OWNER TYPE FREMONT 401 ❑ 4.LOCAL AGENCY/DISTRICT• ® 1 CORPORATION ❑ 5.COUNTY AGENCY" BUSINESS ® L GAS STATION ❑3.FARM [j 5.COMMERCIAL ❑ 2.INDIVIDUAL ❑ •6.STATE AGENCY TYPE ❑ 3PARTNERSHIP 402 ❑2.DISTRIBUTOR ❑4.PROCESSOR E] 6.OTHER 403 . ❑ 7.FEDERAL AGENCY* TOTAL NUMBER OF TANKSIs 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 trustlands? the UST(This is the contact person for the tank records.) 404 ❑ Yes ® No 405 406 II.PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407 PHONE 408 LAL JOGINDER 209 941-2264 MAILING OR STREET ADDRESS 409 1756 N WILSON WAY CITY 411 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 4 III.TANK OWNER INFORMATION TANK OWNER NAME 414 PHONE 415 LAL,JOGINDER 209 941-2264 MAILING OR STREET ADDRESS 416 1756 N WILSON WAY CITY 417 1 STATE 418 ZIP CODE 419 STOCKTON CA 95205 TANK OWNER TYPE ❑ 1.CORPORATION ❑ 2.INDIVIDUAL ❑ 4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY ago ❑ 3.PARTNERSHIP ❑ 5.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 421 V.PETROLEUM UST FINANCIAL RESPONSIBILITY INDICATE METHOD(s) ❑ 1.SELF-INSURED ❑4.SURETY BOND ❑ 7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM ❑2.GUARANTEE 115.LETTER OF CREDIT ❑ 8.STATE FUND&CFO LETTER ❑D 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 Z DATE424 PHONE , m O og z© 7 o NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 417 STATE UST FACILITY NUMBER(For local uc onk) 428 1998 UPGRADE CERTIFICATE NUMBER(For local use only) Is 1998 Compliant? UPCF(1/99 revised)