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IFIRD PROGRAM CONSOLIDATED FORTM- TANKS UNDERGROUND STORAGE TANKS - FACILITY (one page per site) Page_of TYPE OF ACTION ❑ 1.NEW SITE PERMIT DJ 3.RENEWAL PERMIT ❑S.CHANGE OF INFORMATION ❑ 7.PERMANENTLY CLOSED SITE (Check one item only) ❑4.AMENDED PERMIT specify change local use only ❑ S.TANK REMOVED ❑&TEMPORARY SITE CLOSURE 400 I. FACILITY/SITE INFORMATION FACILITY BUSINESS NAME(Sameu FACILITYNAMEar D8k D4ins8.mca Aa) IDq My Mini Mart NEAREST CROSS STREET 4d1 FACILITY OWNER TYPE U 4.LOCAL AGENCY/DISTRI (- Bradford ❑ I.CORPORATION ❑5.COUNTY AGENCY" BUSINESS ® 1.GAS STATION 3.FARM U 5. COMMERCIAL ® 2.INDIVIDUAL ❑6.STATE AGENCY" TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR[16. OTHER 403 ❑ 3.PARTNERSHIP ❑7.FEDERAL AGENCY" 402 TOTAL NUMBER OF TANKS Is facility on Indian Reservation or 9f owner of UST is a public agency:name of supervisor of division,aec6an or office which REMAINING AT SITE trustlands7 operates the UST(ibis is the contact person for the tank records.) 2 404 [1 Yes El No 405 406 II. PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407 PHONE 408 Joginder Lal (209) 941-2264 400 MAILING OR STREET ADDRESS 1756 N. Wilson Way CITY 410 STATE 411 ZIP CODE 412 Stockton CA 95205 PROPERTY OWNER TYPE I.CORPORATION M 2.INDIVIDUAL U 4.LOCAL AGENCY/DISTRICT U6.STATEAGENCY ❑3.PARTNERSHIP [:15.COUNTY AGENCY ❑7.FEDERAL AGENCY 413 III.TANK OWNER INFORMATION TANK OWNER NAME 414 PHONE 415 Joginder Lal (209) 941-2264 416 MAILING OR STREET ADDRESS 1756 N. Wilson Way CITY 417 STATE 419 ZIP CODE 419 Stockton CA 95205 TANK OWNER TYPE 1.CORPORATION 2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT LJO.SlAlhAU11f4C1 420 [13.PARTNERSHIP ❑5.COUNTY AGENCY [17.FEDERAL AGENCY IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY K HO 44- 1 1 1 1 1 1 Call 916 322-9669 if questions arise 421 V.PETROLEUM UST FINANCIAL RESPONSIBILITY INDICATE METHOD(s) ❑ 1.SELF-INSURED ❑4.SURETY BOND [17.STATE FUND ❑ 10.LOCAL GOVT MECHANISM ❑2.GUARANTEE ❑5.LETTER OF CREDIT ®8.STATE FUND&CFO LETTER ❑ 99.OTHER: ❑3.INSURANCE [16.EXEMPTION ❑9.STATE FUND&CD 422 VI.LEGAL NOTIFICATION AND MAILING ADDRESS Checkova box m indicate which address should be used for legal notifications and mailing. Legal notifications and mailings will be sent to the tank owner unless box 1 or 2 is checked. ❑ 1.FACILITY El 2. PROPERTY OWNER ❑3.TANK OWNER 423 VII.APPLICANT SIGNATURE Certification-1 certify that the information provided herein is one and accurate to the beat of my knowledge. Sl NATURE OF APPLICANT DATE 424 PHONE 425 ef e (209) 941-2264 NAM OF APPLICANT(print) 426 TITLE OF APPLICANT 427 Joginder Lal Owner STATE UST FACILITY NUMBER(For mal asn Doty) 428 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 UPCF(1/99 revised) 8 Formerly SWRCB Form A