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IFIED PROGRAM CONSOLIDATED FORM PR#:PRO231173 J FAC N:FA0006423 ' UNDERGROUND STORAGE TANKS - FACILITY y (one page per site) TYPE OF ACTION ❑ LNEW SITE PERMIT ❑ 3.RENEWAL PERMIT 5.CHANGE OF INFORMATION ❑ ].PERMANENTLY CLOSED SITE (Check one item only) ❑ 4.AMENDED PERMIT ❑ 8.TANK REMOVED ❑6.TEMPORARY SITE CLOSURE 400 I.FACILITY/SITE INFORMATION 3440 E MAIN ST.STOCKTON BUSINESS NAME issme se FACILITY NAME or DBA-Dong Business As) y FACILITY ID# PR 07# UNITED CTAS FA0006423 PR0231173 NEAREST CROSS STREET FACILITY OWNER TYPE ❑ 4_LOCAL AGENCY/DISTRICT- MAIN 401 ION ❑ 5.COUNTYAGENCY* BUSINESS 1.GAS STATION ❑ 3.FARM ❑ 5.COMMERCIAL 2.INDIVIDUAL ❑ 6.STATEAGENCY+ TYPE ❑ 2 DISTRIBUTOR ❑ 4.PROCESSOR ❑ 6.OTHER 403 ❑ 3.PARTNERSHIP E] 402 ].FEDERAL AGENCY- TOTAL NUMBER OF TANKS Is facility on Indian Reservation or +Ifowner of UST is a public agency:name ofsupervisor ofdivision,section or office which operates REMAINING AT SITE trusllands? the UST(This is the contact person for the tank records) 3 04 ❑ Yes ® No 405 4% II.PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 40] PHONE 408 CR ANCW AAR14f o eeA PT-*W 1+R u r MAILING OR STREET ADDRESS 409 s CITY 410 STATE 411 ZIP CODE 412 tes-s>ttes !� I CA -93�3a PROPERTY OWNER TYPE I.CORPORATION 2.INDIVIDUAL El 4.LOCAL AGENCY/DISTRICT El 6.STATE AGENCY 9$3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY 413 III.TANK OWNER INFORMATION TANK OWNER NAME 414 PHONE 415 r`D Al\i!-'V AAATTIT o MAATT\IICTrvjj 4 MAILING OR STREET ADDRESS 1 n 416 CITY 41STATE 413 ZIP CODE 419 -h0S-Gr;T4@& tC,5 CA =xeae > TANK OWNER TYPE -N-F69Rf9160eTION 2.INDIVIDU ❑ 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- 44-000030 1 Call(916)322-9669 if 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 115.LETTER OF CREDIT &STATE FUND&CFO LETTER ❑K 99.OTHER ❑3.INSURANCE ❑6.EXEMPTION z 9 .h""""am e' 422 VI.LEGAL NOTIFICATION AND MAILING ADDRESS Check one box to indicate which address should be used for legal notifications and mailing. ® I.FACILITY ❑2.PROPERTY OWNER El 3.TANK OWNER 413 Legal notifications and mailing will be sent to the tank owner unless box 1 or 2 is checked. VII.APPLICANT SIGNATURE Certification-I cenify that the information provided herein is true and accurate to the best of my knowledge. 'p SIGNATURE OF APPLICANT DATE 424 /,vh �I ^f 0 425 113 t d PHO NE NAME OFAPF49VANT(pri ) 426 TI E OF LICArilT 427 AAA OWNER STATE EST rFACILITY NUMBER(Forladuceoly) 428 1998 UPGRADE CERTIFICATE NUMBER For lord use od.) 429 Is 1998 Compliant?Y UPCF(1/99 revised)