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Imo- FIED PROGRAM CONSOLIDATED FO PR#:PR0231173 r n \lU FAC#:FA0006423 JAN '3) 004 S -FACILITY UNDERGROUND STORAGE TANKMOO ��11``I/��jj�� },�J t�NGEF (one page per site) \'TYPgrF ys(ks(pDp�D!plIrVItIJ�H PERMIT ❑ 3.RENEWALPERMITRMATION ❑ ].PERMANENTLY CLOSED SITE (Check o}9MI1'Ifl/SERVICES ❑ 4.AMENDED PERMIT v ❑ S.TANK REMOVED MPORARY SITE CLOSURE Opo L FACILITY/SITE INFORMATION 3440 E MAIN ST STOCKTON BUSINESS NAME(sarcuFAcarrvNAnm ar DBA-DoirnS Business 7d, GILITY ID# PR ION a n t¢GOfA0006423 PR0231173 FACI[.ITY OWMAIN 401 ❑ 1.CORPORATION ❑d.LOCAL AGENCY/DISTRICT•BUSINESS TION ❑ 5.COUNTYAGENCY'TYPE ❑ 3.FARM L ❑ 2.MDNHDUAL ❑ 6.$TATE AGENCY+2.DISTRIBUTOR ❑ 4.PROCESSOR4m ❑ 3.PARTNERSHIP 402 ❑ 7.FEDERALAGENCY•TOTAL NUMBER OF 7ANKS Is facility on +Yawner ofUST isa blicarnREMAINING A7 SITE tonstlands? Pu g ry:name of supervisor ofdivisian,section or office wM1ich operates Ne UST(This is the contact person for the tank records.) 004 ❑ Yes ® 4os 06 II.PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 90.1 PHONE 408 �+ FRANCY AMIDI&MATT WEILER MAILING OR STREET ADDRESS 15814 WINCHESTER BLVD 103 409 CITY Oto STATE 411 ZIP CODE 4¢ LOS GATOS CA 95030 PROPERTY OWNER TYPE El I.CORPORATION El2.INDIVIDUAL ❑ 4.LOCAL AGENCY I DISTRICT ❑ 6.STATE AGENCY ®3.PARTNERSHIP [15.COUNTY AGENCY ❑ 7.FEDERAL AGENCY 413 1II.TANK OWNER INFORMATION TANK OWNER NAME 414 PHONE FRANCY AMIDI&MATT WEILER 415 MAILING OR STREET ADDRESS 15814 WINCHESTER BLVD 103 416 CITY 417 STATE sla ZIP CODE 410 LOS GATOS I CA 95030 TANK OWNER TYPE ❑X I.CORPORATION ❑ 2.INDIVIDUAL 1:14.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 Call(916)322-9669 if questions arise 421 V.PETROLEUM UST FINANCIAL RESPONSIBILITY INDICATE METHOD(s) ❑ 1.SELF-INSURED ❑4.SURETY BOND - '& ^ ff""^ca•ND ❑ 10.LOCAL GOVT MECHANISM ❑2.GUARANTEE ❑5.LETTER OF CREDIT ❑ 8.STATE FUND&CFO LETTER 99.OTHER ❑3.INSURANCE ❑6.EXEMPTION ❑ 9.STATE FUND&CD VI.LEGAL NOTIFICATION AND MAILING ADDRESS Check one box to indicate which address should be used for legal notifications and nailing. ® 1.FACILITY ❑2.PROPERTY OWNER ❑ 3.TANK OWNER 423 Legal notifications and mailing will be sent to the tank owner unless box I or 2 is checked. VII.APPLICANT SIGNATURE Cenificatio mfy that the information pro rein is true and accurate to the best army knowledge. O SIGNA URE OF APPLICANT DATE 42 PHONE 4 s 1111-#- C4S NAME OF APPLi (print) 426 TITLE OF APPLICANT STATE UST FACILITY NUMBER(Por lo®I w owy) 429 1998 UPGRADE CERTIFICATE NUMBER(Forlocel use only) 420 Is 1998 Compliant?Y UPCF(1/99 revised)