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FIED PROGRAM CONSOLIDATED F 6 M <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY a» so <br /> Page _ or <br /> TYPE OF ACTION V. 0 7 PERMANENTLY CLOSED SITE <br /> (Chock One'him-tY) 1.NEIN SITE PERMR 0 3.RENEWAL PERMIT ❑ ) C we OF INFORMATION(Speai/y Mangs- 0 a TANK REMOVED 400 <br /> ❑ {.AMENDED PERMIT w1,) <br /> '� �L,t;.�. 1.FACILITY 1 SITE INFORMATION <br /> BUSINESS NAME(Same u FACILITY NAME a DBA Doolg Bu+inee+AU ] FAGLITY ID a ; <br /> My Mini Mart <br /> NEAREST CROSS STREET 4o1 FACILm OVMER TYPE 0 4 LOCAL AGENCYAWRICT' <br /> College Avenue 0 1. CORPORATION 0 5. COUNTYAGENCr <br /> Ca 2. INDIVIDUAL 0 a. STATE AGENCY, <br /> BUSINESS 1,GAS STATION ❑ 3.FARM 0 S.COMMERCIAL ❑ 3, PARTNERSHIP 0 7. FEDERAL AGENCY' 402 <br /> TYPE <br /> ❑ 2.DISTRIBUTOR ❑ 1.PROCESSOR ❑ e.OTHER 403 <br /> 2PROPERTY <br /> TANKS Y nM4en tel+^ReeaiMlan a d,,,,. was P,,or erapl s+Y�gla issime Of U of <br /> (TIIu le ins cenract pawn far tlr bnR ncada) 108 <br /> 404 ❑Yes M No 405 <br /> U.PROPERTY OWNER INFORMATION PHONE +�R NAME (209) 474-7532 <br /> netteHoag 439 <br /> ET ADDRESS <br /> 7201 Pacific Avenue412 <br /> 410 ATE 411 CODE <br /> CITY CA 95202 <br /> Stockton <br /> PROPERTY OWNER TYPE KI 2. INDIVIDUAL 0 4. LOCAL AGENCY I DISTRICT 0 a. STATEAGENCY 413 <br /> ❑ 1. CORPORATION 0 3. PARTNERSHIP ❑ 5. COUNTY AGENCY ❑ 7. FEDERAL AGENCY <br /> UL TANK OWNER INFORMATION <br /> 414 PHONE 115 <br /> TANK OWNER NAME (209) 474-7532 <br /> Annette Hoag 416 <br /> MAILING OR STREET ADDRESS <br /> 7201 Pacific Avenue 1„ STA .,e zlPcoDE 419 <br /> CITY CA 95202 <br /> Stockton <br /> TANK OWNER TYPE � 2. INDIVIDUAL ❑ I. LOCAL AGENCY/DISTRICT ❑ 8. STATE AGENCY <br /> 420 <br /> 0 1 CORPORATION 0 3. PARTNERSHIP ❑ 5. COUNTYAGENCY 0 7. FEDERALAGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> 421 <br /> TY(TK)HO 4 4 <br /> Call(916)322,96W It quaelions arise <br /> V. PETROLEUM UST FINANCIAL RESPONSUIILITY <br /> INDICATE METHOO(S) 0 1_ SELF-INSURED 0 4. SURETYBOND ® 7. STATE FUND 0 10 LOCAL GOVT MECHANISM <br /> O 1, GUARANTEE ❑ 5 LEnEROFCREDIT ❑ 8 STATE FUND 8 CFO LETTER ❑ 99 OTHER 422 <br /> Cl 3. INSURANCE 0 9. EXEMPTION ❑ 9. STATEFUNOa CD <br /> VL LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one Goa M indKSM Wn address aMUIC w"eadi tar legal noMicabona aid mod" ❑ 1. FACILITY 2. PROPERTY OWNER ❑ 3. TANK OWNER 423 <br /> Legal notiliabona and mailings mil w wt to a.eank cwwr unless boa 1 or 2 is cMcbd_ <br /> VII.APPLICANT SIGNATURE <br /> CoMil"bon cemfY mat IAe irdormawn poMeO llarwr le we and aecurMa m me pwt a1 my RnavAw9a 424 PHONE 425 <br /> SIGNATURE OF APPLICANT 5/21/99 <br /> 5/21/99 (209) 524-9653 427 <br /> N (prm0 <br /> 428 TITLE OF APPLICANT <br /> AME OF APPLICANT <br /> Agent for Owner <br /> Tim Juif <br /> Formerly SWRCB Farm A <br /> UPCF(IW) <br />