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41FIED PROGRAM CONSOLIDATED FORM. {... r r4\ PIR#:PRO505151 ..r I U FAC#:FA0007815 UNDERGROUND STORAGE TANKS - FACILITY 6( 165 (one page per site) TYPE OF ACTION ❑ I.NEW SITE PERMIT ❑ 3.RENEWAL PERMIT 5.CHANGE OF INFORMATION ❑ 7.PERMANENTLY CLOSED SUE (Check one item only) ❑ 4,AMENDED PERMIT fa®luxosh ❑ 8.TANK REMOVED [:]6 TEMPORARY S111 CI IMllt II 400 I.FACILITY/SITE INFORMATION 707 E YOSEMITE AVE MANTECA BUSINESS NAME(sana:as FACILm NAMExDEA-Doing Bas 5s As) 3 FACILITY IDM PR")aUICKI-KLEEN CAR WASH* FA0007815 PRO505151 NEAREST CROSS STREET FACILITY OWNER TYPE YOSEMITE of M1.CORPORATION ❑4 LOCALY AGENCY- BUSINESS CT• BUSINESS ❑ 2.INDIVIDUAL ❑ 5.COUNTY AGENCY- TYPE ❑ 1.GAS STATION ❑ 3.FARM ❑ 5.COMMERCIAL ❑ 6.STATE AGENCY• ❑ 2.DISTRIBUTOR ❑4.PROCESSOR ❑ 6.OTHER 403 ❑ 3.PARTNERSHIP ❑ 3,FEDERAL AGENCY- 402 TOTAL NUMBER OF TANKS Is facility on Indian Reservation or •Ifowner of UST is a public agencyname of sopervlaor of divlsom,section or office which operates REMAINING AT SITE tnsstlands? the UST(This is the contact person for the tank records.) 404 ❑ Yes M No 405 Me II.PROPERTY OWNER INFORMATION J PROPERTY OWNER NAME 407 PHONE MR M Ar A a",> 209 823-9159 MAILING ORS ET ADDRESS My 450 FIRST ST CITY 410 STATE 411 ZIP CODE 412 ESCALON CA 95320 J PROPERTY OWNER TYPE ® 1.CORPORATION ❑ 2.INDIVIDUAL El 4.LOCAL AGENCY/DISTRICT 06.STATE AGENCY [13.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY 413 III.TANK OWNER INFORMATION / TANK OWNER NAME 414 PHONE _ ��_�� 411 );q A)c Lam' ell e- rlv"'l MAILING OR STREET ADDRESS r.rr�e-riac�roT 9s� /w,,d6eY c¢ 416 CITY 412 STATE 41 1 ZIP CODE 419 �EsetrM CA 94;20.- TANK 5329TANK OWNER TYPE (] 1.CORPORATION ❑ 2.INDIVIDUAL ❑ 4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY 420 ❑ 3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY(TK)HQ 44- Call(916)322-9669-'-P questions arise 421 V.PETROLEUM UST FINANCIAL RESPONSIBILITY INDICATE METHOD(s) ❑ 1.SELF-INSURED ❑4.SURETY BOND ❑ 7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM / ❑2.GUARANTEE ❑5.LETTER OF CREDIT ❑ 8.STATE FUND&.CFO LETTER 19199.OTHER ❑ 3.INSURANCE 116.EXEMPTION ❑ 9.STATE FUND&CD 423 VI.LEGAL NOTIFICATION AND MAILING ADDRESS Check one bon to indicate which address should be used for legal notifications and mailing. ® 1.FACILITY ❑2.PROPERTY OWNER 03.TANK OWNER 423 Legal notifications and mailing will be sent to the tank owner unless box 1 or 2 is checked. VII.APPLICANT SIGNATURE Certification-I certify that disinformation provided herein is true and accurate to the best of my knowledge. J SIGNATURE APPLICANT DATE 424 PHONE 425 05 0 3 -ate 0-40 8�0 -�sa NXIM OF AP CANT(print) 426 TITLE OF APPLICANT 4D 7I/R NL`e N .R- -;F A) STATE UST FACILITY NUMBER(Fin host-only) 428 1998 UPGRADE CERTIFICATE NUMBER(Far laml uv:ort.) 429 Is 1998 Compliant?Y UPCF(1/99 revised)