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0IFIED PROGRAM CONSOLIDATED FORM• PR#:PRO523165 FAC#:FA0015637 UNDERGROUND STORAGE TANKS - FACILITY 4 (one page per site) ID may.ISI 1Au' TYPE OF ACTION ❑ L NEW SITE PERMIT ❑ 3.RENEWAL PERMIT ❑ 5,CHANGE OF INFORMATION ❑ 7.PERMANENTLY CLOSED SITE (Check one item only) ❑4.AMENDED PERMIT ❑ S.TANK REMOVED Y ❑6.TEMPORARY SITE CLOSURE 400 I.FACILITY/SITE INFORMATION 4"E WEBER AVE,STOCKTON I �h BUSINESS NAME(Samc se FACILITY NAME or DBA-Doing Busiaws As) 3 FACILITY ID# PR ION HOTEL STOCKTON INVESTORS FA0015637 PRO523165 NEAREST CROSS STREET FACILITY OWNER TYPE N 1.CORPORATION El 4.LOCAL YAGENCY'AGENCY/DISTRICT- 401 El 5.COUNTY AGENCY' BUSINESS r-1I.GAS STATION ❑ 3.FARM E] 5.COMMERCIAL ❑ 2.INDIVIDUAL ❑ 6.STATE AGENCY' TYPE El 2. 3.PARTNERSHIP [:] 402 2.DISTRIBUTOR 4.PROCESSOR b.OTHER 403 7.FEDERAL AGENCY' TOTAL NUMBER OF TANKS Is facility on Indian Resemadon DI '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 N No 405 406 II.PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407 PHONE 409 209 471-2315 MAILING OR STREET ADDRESS 409 1001 SIXTH ST STE 200 CITY 410 STATE all ZIPCODE 412 SACRAMENTO I CA 1 95814 PROPERTY OWNER TYPE ❑ I.CORPORATION ❑ 2.INDIVIDUAL ❑ 4.LOCAL AGENCY/DISTRICT [16.STATE AGENCY ❑3.PARTNERSHIP [:15.COUNTY AGENCY ❑ 7.FEDERAL AGENCY 413 III.TANK OWNER INFORMATION TANK OWNER NAME 414 PHONE 415 HOTEL STOCKTON INVESTORS 209 471-2315 MARLING OR STREET ADDRESS 416 1001 SIXTH ST STE 200 CITY 417 STATE 419 ZIP CODE 419 SACRAMENTO CA 95814 TANK OWNER TYPE ❑ 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- 1 Call(916)322-9669 if questions arise 421 V.PETROLEUM UST FINANCIAL RESPONSIBILITY INDICATE METHOD(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 N 99.OTHER ❑3.INSURANCE ❑6.EXEMPTION ❑ 9.STATE FUND&CD 422 VI.LEGAL NOTIFICATION AND MAILING ADDRESS Check one bon to indicate which address shodd be used for legal notifications and mailing. El I.FACILITY N 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 we and accurate to the best of my knowledge. SIGNATURE OF APPLICANT DATE 424 1 PHONE 49S NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 427 STATE UST FACILITY NUMBER(For kcd as only) 423 1998 UPGRADE CERTIFICATE NUMBER(For local we only) 429 Is 1998 Compliant? UPCF(1/99 revised)