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FIED PROGRAM CONSOLIDATED FORM PR#:PR0523164 I 4 FAC#: 15636 UNDERGROUND STORAGE TANKS - FACILITY 5� (one page per site) I Itz 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 sphiFbM1 local we only' 6 ❑ 8.TANK REMOVED ❑fi.TEMPORARY SII L CLOSURE 400 I.FACILITY/SITE INFORMATION 666 W WEBER AVE.STOCKTON BUSINESS NAME(smax as FACILITY NAME or DBA-Deieg BusiresS As) y FACILITY IDN PR ID# STOCKTON REDEVELOPMENT AGENCY FA0015636 PRO523164 NEAREST CROSS STREET FACILITY OWNER TYPE ml ® I.CORPORATION ❑ 4.COUNTYACAL AGENCY'❑ S.COUNTY AGENCY• BUSINESS ❑ 1.GAS STATION EJ3.FARM ❑ 5.COMMERCIAL E] 2.INDIVIDUAL [:1 6.STATE AGENCY' TYPE ❑ 2.DISTRIBUTOR ❑ 4.PROCESSOR ❑ 6.OTHER 403 ❑ 3.PARTNERSHIP [:1 7. 402 ].FEDEAGENCY• 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 SrM trustlands? the UST(This is the contact person for the tank records.) 404 ❑ Yes ® No 405 406 II.PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 403 PHONE408 CITY OF STOCKTON (209) 209 937-8377 MAILING OR STREET ADDRESS 409 425 N EL DORADO ST CITY 410 STATE 411 ZIP CODE 412 STOCKTON I CA 1 95202 PROPERTY OWNER TYPE ❑ 1.CORPORATION ❑ 2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY ❑3.PARTNERSHIP [15.COUNTY AGENCY ❑ 7.FEDERAL AGENCY 413 III.TANK OWNER INFORMATION TANK OWNER NAME 414 PHONE 415 CITY OF STOCKTON 209 937-8377 MAILING OR STREET ADDRESS 416 425 N EL DORADO ST CITY 417 STATE 418Z P CODE 419 STOCKTON CA 95202 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 621 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 19199.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 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 true and accurate to the best of my knowledge. SIGNATURE OF APPLICANT DATE 424 1 PHONE 435 NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 437 STATE UST FACILITY NUMBER(For low ac only) 028 1998 UPGRADE CERTIFICATE NUMBER(F«kral eK.*) 429 Is 1998 Compliant? UPCF(1/99 revised)