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'FIED PROGRAM CONSOLIDATED FORM PR#:PRO231028 wow FAC#.-FA0003811 UNDERGROUND STORAGE TANKS - FACILITY R T` If (0-7 (one page per site) 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 V_ ❑ S.TANK REMOVED ❑6.TEMPORARY SITE CLOSURE 411" I.FACILITY/SITE INFORMATION 4950 BUCKLEY COVE WAY STOCKTON BUSINESS NAME(Same as FACILITY NAME cs DHA-[sang Rusin ss As) 3 FACILITY IDIi I PR IDN l RIVER POINT LANDING MARINA-RESORT* FA0003811 PR0231028 NEAREST CROSS STREET 401 FACILITY OWNER.TYPE © 4.LOCAL AGENCY/DISTRICT* M 1.CORPORATION ❑5-COUNTY AGENCY•. BUSINESS ❑ I GAS STATION ❑ 3.FARM ❑ 5.COMMERCIAL ❑ 2.INDIVIDUAL ❑6..STATE AGENCY* TYPE ❑ 2.DISTRIBUTOR ❑ 4.PROCESSOR ❑ 6 OTHER403 ❑ 3.PARTNERSHIP El 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 trustlands? the UST(This is the contact person for the tank records) 404 ❑ Yes ® No 405 416 II.PROPERTY OWNER INFORMATION 1 PROPER T OWNER NAME 407 PHONE 408 TUC, K L E ,Lr � C)U 209 951-4144 MAILING OR STREET ADDRESS - 409 U EL Uc'a2�c�0 S "I" CITY 410 STATE 411 ZIP CODE 412 STOCKTON CA PROPERTY OWNER TYPE ❑ I CORPORATION ❑ 2.INDIVIDUAL 4.LOCAL AGENCY I DISTRICT ❑ 6.STATE AGENCY ❑3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY 413, II1.TANK OWNER INFORMATION TANK OWNER NAME 414PHONE 41, STEPHENS ANCHORAGE 209 951-4144 f MAILING OR STREET ADDRESS 416 PO BOXJPW 4 9 s CITY 417 STATE 418 ZIP CODE 419 STOCKTON I CA14-5� (1152.&-7 TANK OWNER TYPE / 1.CORPORATION ❑2.INDIVIDUAL ❑ 4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY 421) ❑ 3.PARTNERSHIP COUNTY AGENCY ❑ 7.FEDERAL AGENCY IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY(TK)HQ 44- Call(916)322-9669 if questions arise 421 V.PETROLEUM UST FINANCIAL RESPONSIBILITY INDICATE METHOD(s) ❑ 1.SELF-INSURED ❑4.SURETY BOND ( E] 7.STATE FUND El 10.LOCAL GOVT MECHANISM El 2.GUARANTEE ❑ 5.LETTER OF CREDIT" X 8.STATE FUND&CFO LETTER N,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 4'3 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 SIGNATUREOF AP NT DATE 424 PHONE 425 azo 97, ` qtl AleNAME OF APPLICANT(print) 426 TITLE OF(APPLICANT 427 LI+�{ 1 Pt1�AS +4ArGbfMASTBT STATE UST FACILITY NUMBER(Fm lac I ne o„h) 428 1998 UPGRADE CERTIFICATE NUMBER tear local use onlc) 429 Is 1998 Compliant?Y UPCF(1199 revised)