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NIFIED PROGRAM CONSOLIDATED FORT`S it Iwo? PR#:PRO505151 <br /> FAC#:FA0007815 <br /> UNDERGROUND STORAGE TANKS -FACIL a p/`/D3 <br /> �����x,,,,,...�J.......,,,,,(((( (one pa site) l <br /> TYPE OF ACTION Ell.NEW SITE PERMIT �3.RENEWAL PERMIT ❑ 5.CRANGEOFINFORMATION ❑ 7.PERMANENTLY CLOSED SITE <br /> (CM1eck one item only) ❑ 4.AMENDED PERMIT ❑ 8.TANK REMOVED <br /> 1:16.TEMPORARY SITE CLOSURE 400 <br /> I.FACILITY/SITE INFORMATION 707 E YOSEMITE AVE.MANTECA <br /> BUSINESS NAME mar as FACR.mNAME or DBA-Doing Human As) 3 FACILITY ID# PR IN <br /> PONTES UICKI-KLEEN CAR WASH* FA0007815 PR050515I <br /> NEAREST CROSS STREET I FACILITY OWNER TYPE ❑ 4,LOCAL AGENCY/DISTRICT- <br /> 401 ❑ L CORPORATION <br /> YOSEMITE ❑ s.coUNTvncENcv <br /> BUSINESS 2.INDIVIDUAL <br /> TYPE ❑ I.GAS STATION ❑ 3.FARM ❑ 5.COMMERCIAL 3.PARTNERSHIP ❑ 6.STATE AGENCY' 402 <br /> ❑ 2.DISTRIBUTOR ❑4.PROCESSOR ❑ 6.OTHER 403 ❑ 7.FEDERAL AGENCY• <br /> TOTAL NUMBER OF TANKS Is�facilityonan Reservation orgfowner ofUST is a public agrncy:name ofsopervisor of disision,section or office which apentes <br /> REMAINING AT SITE trthe UST(This is the contact person for the tankrecords.) <br /> 404 ❑ 0 405 406 <br /> 11.PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408 <br /> 209 823-9159 <br /> MAILING OR STREET ADDRESS 409 <br /> 19441 SUTCLIFF AVE <br /> CITY 410 STATE 411 Ze CODE 412 <br /> ESCALON I CA 95320 <br /> PROPERTY OWNER TYPE ® L CORPORATION ❑ 2.INDIVmUAL ❑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 414PHONE 413 <br /> PONTES E&M L 209 823-9159 <br /> MAILING OR STKEET ADDRJnSS 416 <br /> 19441 SUTCLIFF AVE <br /> CITY 417 STATE 418 ZIPCODE 419 <br /> ESCALON I CA 95320 <br /> TANK OWNER TYPE © L CORPORATION ❑ 2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY 420 <br /> ❑ 3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY <br /> FY.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- Call(916)322-9669 if questions arise 0i1 <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 ❑ 8.STATE FUND&CFO LETTER ❑X 99.OTHER <br /> ❑3.INSURANCE ❑ 6.EXEMPTION ❑ 9.STATE FUND&CD 422 <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one box m indicate which address should be used for legal notifications and mailing. ® 1.FACILITY ❑2.PROPERTY OWNER ❑ 3.TANK OWNER 423 <br /> Legal notifications and mailing will be sent to the rank owner unless box I or 2 is checked. <br /> VII.APPLICANT SIGNATURE <br /> Certification-I certify that the information pmsidcd herein is Rue and accurate In the ben ofmy knowledge. <br /> SIGNATURE OF APPLICANT DATE 424 PHONE 415 <br /> NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 427 <br /> STATEUSTFACHITYNUMBER(Forkaurmy) 428 1998 UPGRADE CERTIFICATE NUMBER(Factood os-i,) 429 <br /> Is 1998 Compliant?Y <br /> UPCF(1/99 revised) <br />