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IFIED PROGRAM CONSOLIDATED FORM Z ,M rj PRO:PROSM151 <br /> ( FAC#:FA0007815 <br /> UNDERGROUND STORAGE TANKS - FA tof- �D� <br /> (one page per site) <br /> TYPE OF ACf10N ❑ 1.NEW SITE PERMIT ❑ 3.RENEWALPERMIT 5.CHANGE OF MFORMAIIO� ❑ ).PERMANENTLY CLOSED SITE <br /> (Check one item only) ❑4.AMENDED PERMIT "`' + '"' ❑ 8.TANK REMOVED <br /> gk <br /> ❑b.TEMPORARY SITE CLOSURE 6po <br /> I.FACILITY/SITE INFORMATION 707 E YOSEMITE AVE.MANTECA <br /> BUSINESS NAME(s,me a.FACILITY NAME or DBA-Doing B+ninesa N) FACILITY ID# PR ION <br /> PONTES VICKI-KLEEN CAR WASH* FA0007815 PRO505151 <br /> NEAREST CROSS STREET 401 FACILITY OWNER TYPE ❑ 4.LOCAL AGENCY/DISTRICT' <br /> YOSEMITE ❑ 1.CORPORATION ❑ 5.COUNTY AGENCY" <br /> BUSINESS I GAS STATION ❑ 3.FARM ❑ 5.COMMERCIAL A2.EJDIVIDUA. ❑ 6.STATE AGENCY- <br /> TYPE ❑ 3.PARTNERSHIP ❑ 7,FEDERAL AGENCY- <br /> IS <br /> GENCY- d02 <br /> 2.DISTRIBUTOR ❑ 4.PROCESSOR ❑ b.OTHER 4os <br /> TOTAL NUMBER OF TANKS E facility on Indian Reservation or •Ifowner ofUST is a public agency:name of supervisor of division,section or office which operates <br /> REMAINING AT SITE a-� trustlands? the UST(This is the contact person for the tank records.) <br /> So ❑ Yes ® No 405 °os <br /> II.PROPERTY OWNER INFORMATION <br /> PR P RTYY OWNER Nr 40y PHONE 408 <br /> �1 l/.--� 209 823-9159 <br /> OR S 1 ET ADDRESS 409 <br /> V K `_ <br /> CITY 410 STATE 411 ZIP CODE 4¢ <br /> ESCALON CA 1 95320 <br /> PROPERTY OWNER TYPE g 1.CORPORATION2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT El6.STATE AGENCY <br /> 3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY 415 <br /> III.TANK OWNER INFORMATION <br /> 414PHONE 415 <br /> TANK OWNER NAME <br /> P S a'^�' � fb 209 823-9159 <br /> MAILING OR STREET ADDRESS 416 <br /> 1944 t a'CT: axrn Jl <br /> CITY an <br /> STATE 41s ZIPCODE 419 <br /> ESCALON CA 95320 <br /> TANK OWNER TYPE $ 1.CORPORATION 1INDIVIDUAL El4.LOCAL AGENCY/DISTRICT El6.STATE AGENCY 420 <br /> 3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- Call(916)322-9669 if questions arise 421 <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ❑ 1,SELF-INSURED 114.SURETY BOND ❑ 7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM <br /> ❑2.GUARANTEE ❑5.LETTER OF CREDIT8.STATE FUND&CFO LETTER 1*99.OTHER <br /> El3.INSURANCE El6.EXEMPTION 9.STATE FUND&CD 422 <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one box to indicate wbich address should be used for legal notifications and mailing. IN 1.FACILITY ❑2.PROPERTY OWNER ❑3.TANK OWNER 423 <br /> Legal notifications and mailing will be sent to the tank owner unless box I or 2 is checked. <br /> VII.APPLICANT SIGNATURE <br /> Certification-I certify that the information provided herein is we and accurate to the best ofmy knowledge. <br /> WNF <br /> APPLICANT DATE 41 PHONE 425 <br /> /a ICno 416 TITLE OIfAPPIJCANT 427 <br /> STATE UST FACILITY NUM13ER(For l«al u<v.ly) 428 1998 UPGRADE CERTIFICATE NUMBER(Forlor.I.,e only) 429 <br /> Is 1998 Compliant?Y <br /> UPCF(1/99 revised) <br />