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k 4WIFIED PROGRAM CONSOLIDATED FORIP ja 11ZFAPC a0?FA02�3I6600 957 UNDERGROUND STORAGE TANKS - FACILITY �%'M&) I1ZgU (one pager site) TYPE OF ACTION ❑ I,NEW SITE PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENTLY CLOSED SITE (Check one item only) ❑ 4.AMENDED PERMIT vWfychen$kceluaemly 8.TANK REMOVED ❑6.TEMPORARY SITE CLOSURE 400 1.FACILITY I SITE INFORMATION 14800 S HWY 99.MANTECA BUSINESS NAME(S.as FACILITY NAME or DBA-Doing Business As) 3 FACILITY IDH I PR IDH LATHROP GAS&FOOD MART* FA0000957 PR0231600 NEAREST CROSS STREET FACB.IPY OWNER TYPE ❑ 4,LOCAL AGENCY/DISTRICT' HW4m Y 99 ® 1.CORPORATION ❑ 5.COUNTY AGENCY' BUSINESSEl2.INDIVIDUAL ❑ I.GAS STATION ❑ 3.FARM ❑ 5.COMMERCIAL El 3 PARTNERSHIP ❑ 6.STATE AGENCY' TYPE E]2.DISTRIBUTOR ❑4.PROCESSOR ❑6.OTHER 403 ❑ 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.) as ❑ Yes ® No 405 404 II.PROPERTY OWNER INFORMATION PROPE TY OWNERNA IMERad col PHONE� '- (� 408 AC MAILING OR STREET ADDRESS 409 14700 W. Fp4PTIAciE D CITY ` ��r�,M 410 STATE yI I Z�CODE q�_3 3 J 4I2 IM' li✓PT e 6 PROPERTY OWNER TYPE ® I.CORPORATION El 2.INDIVIDUAL EI 4.LOCAL AGENCY/DISTRICT El 6.STATE AGENCY ❑3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY 413 III.TANK OWNER INFORMATION TANK OWNER NAME 414 PHDNE 415 KAMBOJ,JARNAIL SINGH (209)830-1688 MAIL T ADDRESS 416 r8571' 472-1 CITY I, r�� rgoo417 STATE OIB 01J 33 ZIP CODE 419 TANK OWNER TYPE (] I.CORPORATION ❑ 2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY ago ❑ 3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY TANK OPERATOR INFORMATION TANK OPERATOR NAME TANK OPERATOR TITLE UftRNA' L PRESIDENT IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY(TK)HQ 44- 1 44-024781 1 Call(916)322-9669 if questions arise 421 V.PETROLEUM UST FINANCIAL RESPONSIBILITY INDICATE N ETHOD(s) ❑ I.SELF-INSURED ❑4.SURETY BOND ❑ 7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM ❑2.GUARANTEE ❑5.LETTER OF CREDIT ❑ 8.STATE FUND&CFO LETTER 0 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. ,X, 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. LJ VII.APPLICANT SIGNATURE Certification-1 certify duet the information provided heain is true and accurate to the best of my knowledge. SIGNATURE OF APPLICANT DATE 424 1 PHONE 425 NAME OF APPLICANT(print) 411 =OF APPLICANT 427 STATE UST FACILITY NUMBER(For Iocal ue only) 428 1998 UPGRADE CERTIFICATE NUMBER(Fm Ierel.r ay) 4z Is 1998 Compliant?Y UPCF(1/99 revised)