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FIED PROGRAM CONSOLIDATED FOR1* PR#:PRO505746 V F C#:FA0006977 qpage �2 ZIld6 UNDERGROUND STORAGE TANKS - FACILI per site) TYPE OF ACTION ❑ 1.NEW SITE PERMIT ❑ 3.RENEWAL PERMIT [2,5.CHANGE OF INFORMATION ❑ 7.PERMANENTLY CLOSED SITE (Check one item only) ❑ 4.AMENDED PERMIT spccity change local use onlc ❑ 8.TANK REMOVED ❑6.TEMPORARY SITE CLOSURE- 400 I.FACILITY/SITE INFORMATION 5777 S FRENCH CAMP RD,FRENCH CAMP BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 FACILITY ID# PR ID# TI * G i c S '-el v FA0006977 PR0505746 1 NEAREST CROSS STREET FACILITY OWNER TYPE [_14.LOCAL AGENCY/DISTRICT* 401 FRENCH [91 I.CORPORATION ❑5.COUNTY AGENCY* BUSINESS ^" El 2.INDIVIDUAL TYPE ImoGAS STATION E] 3.FARM ❑5.COMMERCIAL ❑ 6.STATE AGENCY* ❑ 2.DISTRIBUTOR ❑4.PROCESSOR ❑6.OTHER 403 ❑ 3.PARTNERSHIP ❑ 7.FEDERAL AGENCY* 402 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.) V 404 ❑ Yes ® No 405 406 II.PROPERTY OWNER INFORMATION PROPERTY OWNER NAME PHONE 2 a Y �!y 3-y 7�� aos EU TTi C�Tl1T C� T A ATT D.TL'\7L.'i T IL S/ L'I L' /� c5��(�� j�'�) (204 94ft--GM MAILING OR STREET ADDRESS ✓ / l T v 409 Ft{� � 7 7 7 S ` Q✓1 L ��f l IM CITY 1 410 STATE 411 ZIP CODE 412 STOCKTON CA 9S-2A-1- U(� PROPERTY OWNER TYPE 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 jj II r 0 414 PHONE G/ 415 n h Shin v I w,ti Gt f 209 � 94$-09- v MAILING OR STREET ADDRESS 416 CITY 417 STATE 418 ZIP CODE 419 STOCKTON CA 93-26'i- 9)� Z o TANK OWNER TYPE P 1.CORPORATION ❑ 2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 420 ❑ 3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY(TK)HQ 44- 44 U704- -C n 'VA S 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 ❑5.LETTER OF CREDIT 2Y8.STATE FUND&CFO LETTER 19199.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 1 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 424PHONE 9 �/ 425 NAME OF APPLICANT(print) I 426 TITLE OF WPLICANT 427 CK 'N ow n 6 STATE UST FACILITY NUMBER(For local ue onh) 428 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 Is 1998 Compliant?Y UPCF(1/99 revised)