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llf-4A 151j <br /> Rd ° <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> E: (one page per site) Page-of- <br /> TYPE <br /> f_TYPE OF ACTION ❑ 1.NEW SITE PERMIT N 3.RENEWAL PERMIT ❑5.CfIANGE OF INFORMATION ❑ TPERMANENTLY CLOSED SITE <br /> (Check one item only) ❑4.AMENDED PERMIT specify change local use only [3 8.TANK REMOVED <br /> ❑6.TEMPORARY SITE CLOSURE Opp <br /> I. FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Sane as FACILITY NAAIEor DBA-pains Business As) 3 FACILITY 1D# <br /> My Mini Mart 0:1=-FTT I <br /> NEAREST CROSS STREET 401 FACILITY OWNER TYPE ❑4.LOCAL AGENCY/D]STRICT* <br /> Bradford ❑ 1.CORPORATION ❑5.COUNTY AGENCY* <br /> BUSINESS 911.GAS STATION ❑3.FARM ❑5. COMMERCIAL ® 2.INDIVIDUAL ❑6.STATE AGENCY* <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR❑6. OTHER 403 ❑ 3.PARTNERSHIP ❑7.FEDERAL AGCNCY* 402 <br /> 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 <br /> REMAINING AT SITE trustlands? operates the UST(This is the contact person for the tank records.) <br /> 2 404 ❑ Yes IN No 405 <br /> Ooh <br /> IL PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME PHONE 403 <br /> Joginder Lal (2Q9) 941-2264 <br /> MAILING OR STREET ADDRESS 464 <br /> 1756 N. Wilson Way <br /> CITY alp STATE 411 ZIPCODE <br /> 412 <br /> Stockton CA 95205 <br /> PROPERTY OWNER TYPE ❑ I.CORPORATION ®2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY 413 <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME Ota PHON]_ 415 <br /> Joginder Lal (209) 941-2264 <br /> MAILING OR STREET ADDRESS 416 <br /> 1756 N. Wilson Way <br /> CITY alp STATE i8 2[P CODE <br /> Stockton CA 4 95205 414 <br /> TANK OWNER TYPE ❑ 1.CORPORATION 129 2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 42t) <br /> [-13.PARTNERSHIP [:15.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY TK HQ 44- F Call 916 322-9669 if'questions arise 421 <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ❑1.SELF-INSURED ❑4.SURETY BOND ❑7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM <br /> ❑2.GUARANTEE ❑5.LETTER OF CREDIT Q 8.STATE FUND&CFO LETTER ❑ 99.OTHER: <br /> ❑3.INSURANCE ❑6.EXEMPTION ❑9.STATE FUND&CD 422 <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 I or 2 is checked, ❑ 1.FACILITY ®2. PROPERTY OWNER ❑3.TANK OWNER 427 <br /> VII.APPLICANT SIGNATURE <br /> Certification-I certify that the information provided herein is true and accurate to the best of my knowledge. <br /> Sl NATURE OF APPLICANT DATE azo <br /> e PHONE 425 <br /> B `1 (209) 941-2264 <br /> NAM.OF APPLICANT(print) 426 TITLE OF APPLICANT 427 <br /> Joginder Lal Owner <br /> STATE UST FACILITY NUMBER(For local use only) 428 1998 UPGRADE CERTIFICATE NUMBER(For local ucc only) 429 <br /> UPCF(1/99 revised) 8 Formerly SWRCB Fomi A <br />