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o Scfw <br /> • 1 UNITAD PROGRAM CONSOLWATED FORM PRO,PROS16814 <br /> FAC 8:FA0002463 <br /> UNDERGROUND STORAGE TANKS-FACILITY <br /> (one page per site) <br /> TYPEOFAC71ON ❑'1.NEW,SITE PERMIT ❑3.RENEWAL-PERMIT ❑ S.CEANOE OP MFORMAVON ❑7.PERMANENTLY CLOSED SITE <br /> (Cheek one itemodY) ❑4,AMENDED PBRA4lT' <br /> ❑B.TANK RP1.d0YED <br /> ❑&TEMPORARY SITE CLOSURE 400 <br /> I.FACILITY!SITE INFORMATION 678 N WILSON WAY,STOCKTON <br /> B 5 SS AME(Sam4u Pa[aITYNAMHm DHA-poin9&mm�e Re) y <br /> ]FACILITY PR IDM <br /> FOOD 4 LESS" FA0002463 PRO516874 <br /> NEAREST CROSS STREET FACILITY OWNER TYPE <br /> sol ® 1.CORPGRATION ❑4.LOCAI.AOINCYIDISThiCTa <br /> BUSINESS ❑2.MDP/IOUAL ❑x COIlNTYAGENCY• <br /> TYPE I.OAB STATION ❑3.FARM ❑5.cOMhffiriclAL ❑6.STATEAGENCYa <br /> 2..DISPRIRUTOR ❑4,PROCESSOR ❑6.OTHER 4m ❑3.PARTNERSHIP ❑7,PEDPEALAGRNCY• 402 <br /> TOTAL NUMEM OFTANKS Is rncility on <br /> Indian <br /> Reservation of nfawneraUSTisa umiea <br /> REMAININGATSITE trostlsnds7 P Eenry.vme tank.vlser erdiddm,seetiunmoCwe wltirh opaales <br /> Ne UST(Thio is the contact person far the took..,da) <br /> 444 ❑Yes ®No FOOD 4 LESS a05 <br /> 11.PROPERTY OWNER INFORMATION <br /> PROPERTY O ,07 PHONE409 <br /> PA INC 209 957-4917 <br /> MALLIN0 OA STREET ADDRESS <br /> 459 <br /> 8014 LOWER SACRAMENTO RD#I <br /> C177- 410 1 STATE 411ZIP CODE ala <br /> STOCKTON CA 95210 <br /> PROPERTY OWNER TYPE 111.CORPORATION ❑ 2.IDIDIVmUAL Z4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY <br /> ❑3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑7.FEDERAL AOBNCY Y13 <br /> IM TANK OWNER INFORMATION . <br /> TANK <br /> OWNER AI4 PHONE 415 <br /> PA INC 209 957-4917 <br /> MAILING OR STREET ADDRESS <br /> A16 <br /> 8014 LOWER SACRAMENTO RD#I <br /> CITY117 STATE 4m ZIP CODE 415 <br /> STOCKTON CA .95210 <br /> TA14K O TYPE 01 CORPORATION 02.A rviDUAL El 4.LOCAL AGENCY/DISTRICT 116.STATEAGENCY 4aa <br /> ❑3.PARTNERSHIP ❑5.COUNTY AOrNCY ❑7,FBDERALAGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY CM)HQ 44- 44-041773 1 Call(916)322-9669 if questions arise <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(a) ❑ ).SELF-INSURED ❑4.SURETY FOND © 7.STATE FUND 1110,LOCAL 005/T'MECHANISM <br /> 1:12.GUARANTEE ❑5,LETTER OF CREDIT ❑ S.STATE FUND&CFO LETTER ❑99.GIRM <br /> ®3.INSURANCE ❑6.EXEMPTION ❑ 9.STATE FUND&CD Ola <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> cheek one be,w indicate whiahaddrtm should be need forlegalnmi0cedotw and mailing IN 1.FACILITY ❑2.PROPERTY OWNER ❑3.TANK OWNER 423 <br /> Legal w0wtions and mailing will be sent to the tank pwnerunless bos I w2 is checked. <br /> VII. P A T AT <br /> Certification-l;; fyahm the into herein is we and amumte to the but of myknowled0s <br /> S ON IC DATE 434 PHONE <br /> ,as <br /> 2 /ri'o7 2r sF -Dial 3 <br /> NAl,E OF APPLICANT(print) 126 TITLE OF APPLICANT <br /> 4n <br /> /1'x,rm4.,r (� <br /> STATE USTFACFdTYNUMBER(wimo weary) 429 1998UPGRADECERTIECATENOMMRIParlxolueeonty) 429 <br /> Is 1999 Compliant?Y <br /> UPCF(1/99 revised) <br /> ZOO 'd 901099960Z I 'ON Xdd 'HM SS91 dOd CON WV P:90 NOYULOOZ/61/H9d <br />