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() MN IFIED PROGRAM CONSOLIDATED FORK. I o231600 FAC M:FA0000957 ` UNDERGROUND STORAGE TANKS - FACILITY - (one page per site) TYPE OF ACTION ❑ I.NEW SITE PERMIT ❑3.RENEWAL PERMIT ❑ S CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE (Check one item only) ❑ 4.AMENDED PERMIT waifyNoah®mly ❑ 8.TANK REMOVED ❑6,TEMPORARY SITE CLOSURE 400 L FACILITY/SITE INFORMATION 14800 5 HWY 99,MANTECA BUSINESS NAME(San o FACILITY NAME a DSA-Doing aeimtt An FACILITY IDk PR IDk LATHROP GAS&FOOD MART" FA0000957 PRO: 1600 NEAREST CROSS STREET 4aI FACILITY OWNERTYPE C] 4 LOCAL AGENCY/DISTRICT" HWY 99 ® I.CORPORATION ❑ 5.COUNTY AGENCY' BUSINESSC:12.INDIVIDUAL C:] I.GAS STATION ❑ 3.FARM ❑ 5.COMMERCIAL ❑ 3.PARTNERSHIP C1 b.STATE AGENCY" TYPE 402❑ 2.DISTRIBUTOR ❑ 4.PROCESSOR F16.OTHER 403 [:] 7.FEDERAL AGENCY' TOTAL NUMBER OF TANKS Isfacility onlndian Reservation or "If owner of UST is a public agency:name ofsasxrvisor ofdwisiou.section oroffce which operates REMAINING AT SITE trustlands° the UST(This is the contact Person for the tank records.) 404 [3Yes ® No J05 J0i IL PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 47 PHONE 408 KAMBOJ IARNAIL S 209 239-2717 MAILING OR STREET ADDRESS 409 CITY 14800 W FRONTAGE RD STATE 411 ZIP CODE 4i, no - MANTECA CA 95336 PROPERTY OWNER TYPE ® 1.CORPORATION ❑ 2.INDIVIDUAL ❑ 4.LOCAL AGENCY r DISTRICT ❑ 6.STATE AGENCY ❑3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY 413 III.TANK OWNER INFORMATION TANK OWNER NAME 414 PHONE 40 KAMBOJ,JARNAIL SINGH (209)830-1688 MAILING OR STREET ADDRESS 416 1017 MARIGOLD IN CITY 417 STATE 419 ZIP CODE 419 MANTECA I CA 95336 TANK OWNER TYPE ® 1.CORPORATION ❑ 2.INDIVIDUAL [3 4.LOCAL AGENCY/DISTRICT 06.STATE AGENCY i30 ❑ 3.PARTNERSHIP ❑ 5.COUNTY AGENCY [:17.FEDERAL AGENCY TANK OPERATOR INFORMATION TANK OPERATOR NAME TANK OPERATOR TITLE - JARNAIL KAMBOJ PRESIDENT IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY(TK)HQ 44- 44-024781 Call(916)322-9669 if questions arise 421 V.PETROLEUM UST FINANCIAL RESPONSIBILITY INDICATE METHOD(s) Cl 1.SELF-INSURED ❑4.SURETY BOND ❑ 7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM 1-12.GUARANTEE ❑5.LETTER OF CREDIT ❑ S.STATE FUND&CFO LETTER ®99.OTHER ❑3.INSURANCE 1:16.EXEMPTION ❑ 9.STATE FUND&CD 422 V1.LEGAL NOTIFICATION AND MAILING ADDRESS Cheek on,box w aide,inc which address should booted for legal notifications and mailing. ❑ I.FACILITY ®2.PROPERTY OWNER ❑3.TANK OWNER 423 Legal notifications and mailing will be sent to the wk owner unless box I or 2 is checked. VII.APPLICANT SIGNATURE Certification-1 certify information ided herein is one vel accurate to the best of my knowledge. SIGN OF PLIC DATE /O 4x4 PHONE 2 N F APPLICANT fount);C _ 4� TITLE OF APPLICANT � �I n�2 / 427 STATE UST FACILITY NUMBER(F"iooa,) 428 1998 UPGRADE CERTIFICATE NUMBER IFee local memhs 429 Is 1998 Compliant?Y UPCF(1/99 revised)