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UNIFIED PROGRAM CONSOLIDATED FORM <br /> E - - TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY Z3'Ic�7 <br /> (One page per site) Page 1 of 7 <br /> PERMIT <br /> TYPE OF ACTION ❑I.NEW PE <br /> (Check one item only) ❑3.RENEWAL PERMIT ®5.CHANGE OF INFORMATION ❑7.PERMANENTLY CLOSED SITE acc <br /> ❑4.AMENDED PERMIT(Specify change) ❑8.TANK REMOVED <br /> ❑6.TEMPORARY SITE CLOSURE <br /> r I. FACILITY/SITE INFORMATION <br /> BUSINESS NAME(same as FACILITY KAME or DBA-Doing Business As) 3. 7403. [12. <br /> Rai Gas Stations Inc.dba Thornton 76 /1 p <br /> NEAREST CROSS STREET FACILITY OWNER TYPE ❑4.LOCAL AGENCY/DISTRICT* ace. <br /> Davis Road and Thornton Road PORATION ❑5.COUNTY AGENCY* <br /> BUSINESS ®1.GAS STATION ❑3.FARM ❑5.COMMERCIAIVIDUAL ❑6.STATE AGENCY* <br /> TYPE ❑2.DISTRIBUTOR [14.PROCESSOR <br /> ❑6.OTHER ❑3.PARTNERSHIP ❑7.FEDERAL AGENCY* <br /> TOTAL NUMBER OF TANKS 404. Is facility on Indian Reservation 405. *If owner UST is a public agency:name of supervisor of division,section or 406. <br /> REMAINING AT SITE or trust lands? office whicof h operates the UST. (This is the contact person for the tank records.) <br /> 3 ❑Yes ®No <br /> 11. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE <br /> aos. <br /> Amar'it S.Rai and Kashmir K.Rai (209)478-8959 <br /> MAILING OR STREET ADDRESS <br /> 10944 Flaming Star Lane 409. <br /> CITY <br /> 410.LCA <br /> ATE �411. ZIP CODE <br /> 412. <br /> Stockton 95209 <br /> PROPERTY OWNER TYPE ❑ 1.CORPORATION ®2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 413. <br /> ❑3.PARTNERSHIP [:15.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME aia. PHONE <br /> 415. <br /> Amar'it S.Rai and Kashmir K.Rai (209)478-8959 <br /> MAILING OR STREET ADDRESS <br /> 416>. <br /> 10944 Flaming Star Lane <br /> CITY an.JC:A <br /> TE <br /> Stockton aix. =5209 <br /> E 419 <br /> TANK OWNER TYPE ❑l CORPORATION ®2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 420. <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 1C`j 4 1 1,;v <br /> Call 916 322-9669 ifquestions arise 421. <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ❑1.SELF-INSURED ❑4.SURETY BOND [17.STATE FUND ❑10.LOCAL GOVT MECHANISM <br /> ❑2.GUARANTEE ❑5.LETTER OF CREDIT ®8.STATE FUND&CFO LETTER 422. <br /> ❑3.INSURANCE [16.EXEMPTION ❑9.STATE FUND&CD ❑`� OTHER: <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one box to indicate which address should be used for legal notifications and mailing. <br /> Legal notifications and mailings will be sent to the tank owner unless box 1 or 2 is checked. ❑ 1.FACILITY ®2. PROPERTY OWNER [:13.TANK OWNER 423. <br /> VII.APPLICANT SIGNATURE <br /> Certification: I certify that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNATURE OF PPLICANT J DATE 424. PHONE 425. <br /> 'f S -� ' D 1--D i oZaQg (209)478-8959 <br /> NAME OF APPLICANT(print) 426. TITLE OF APPLICANT 427. <br /> Amarjit S.Rai Owner <br /> STATE UST FACILITY NUMBER(Agency use On],) 428. 1998 UPGRADE CERTIFICATE NUMBER(Agency use only) 4211. <br /> (See Data Element 1,above. <br /> UPCF Hwfwre-a(1/99)-1/2 www.unidocs.org Rev.02/16/00 <br />