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..2r i-ROGRAM CONSOLIDATED FORM PR#:PRO231441 <br /> .� pWS-L 003604 <br /> UNDERGROUND STORAGE TANKS - FACILITY A',JI/ <br /> (one page per site) <br /> TYPE OF ACTIbN ❑ I.NEW SITE PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENTLY'CLOSED SITE <br /> (Check one item only) ❑ 4.AMENDED PERMIT ❑ 8.TANK REMOVED <br /> ❑b.TEMPORARY SITE CLOSURE <br /> 00 <br /> I.FACILITY/SITE INFORMATION 470 N MAIN ST.MANTECA <br /> BUSINESS NAME(S.as FACILITY NAME or DBA-Doing easmcs..As) 2 FACILITY IDI PI ID# 1 <br /> BEACON STATION#3492* FA0003604 PR0231441 <br /> NEAREST CROSS STREET FACILITY OWNER TYPE ❑ q.LOCAL AGENCY/DISTRICT• <br /> 401 ® L CORPORATION <br /> ❑ 5.COUNTY AGENCY' <br /> MAIN ❑ 2 INDIVIDUAL ❑ 6 STATE AGENCY' <br /> BUSINESS ❑ 1 GAS STATION ❑ 3.FARM ❑ 5.COMMERCIAL 402 <br /> TYPE 403 ❑ 3.PARTNERSHIP ❑ 7,FEDERAL AGENCY' <br /> ❑ 2.DISTRIBUTOR ❑ 4.PROCESSOR ❑ 6.OTHER <br /> TOTAL NUMBER OF TANKS Is facility on Indian Reservation or of owner ofUST is a public agency name of supervisor of divisma,section or once which operates <br /> REMAINING AT SITE trustlands? the UST(This is the contact person for the tank records.) <br /> 406 <br /> 401 ❑ Yes N No 405 <br /> Pr 11.PROPERTY OWNER INFORMATION <br />,. 407 PHONE 409 <br /> PROPERTY OWNER NAME 209 583-3235 <br /> ULTRAMAR INC 409 <br /> MAILING OR STREET ADDRESS <br /> 685 W THIRD ST STATE 411 ZIP CODE 412 <br /> CITY 410 <br /> CA 93230-5000 <br /> HANFORD <br /> PROPERTY OWNER TYPE ® 1.CORPORATION ❑ 2.INDIVIDUAL [:14.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY <br /> E:13.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑7.FEDERAL AGENCY 413 <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> 209 583-3235 <br /> ULTRA MAR INC alb <br /> MAILING OR STREET ADDRESS <br /> 685 W THIRD ST STATE 419 ZIP CODE v <br /> CITY 417 <br /> HANFORD CA 93230-5000 <br /> TANK OWNER TYPE ❑X 1,CORPORATION E:1 2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY 4zc <br /> ❑ 3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7,FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> Jxl <br /> TY(TK)HQ 44- 44-024660 Call(916)322-9669 if questions arise <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ❑ I.SELF-INSURED [:14.SURETY BOND ❑ 7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM <br /> ❑2.GUARANTEE ❑5.LETTER OF CREDIT ❑ 8.STATE FUND&CFO LETTER M 99.OTHER 422 <br /> El3.INSURANCE El6.EXEMPTION ❑ 9.STATE FUND&CD <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one box w indicate which address should be used for legal notifications and mailing. ® L FACILITY ❑2.PROPERTY OWNER [:13.TANK OWNER 423 <br /> Legal notifications and mailing will be sent to the tank owner unless box 1 or 2 is checked. <br /> VII.APPLICANT SIGNATURE <br /> Certification-I certify that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNATURE OF APPLICANT DATE 4x4 PHONE ass <br /> NAMEOF APPLICANT(print) 426 TITLE OF APPLICANT 427 <br /> 629 <br /> STATE UST FACILITY NUMBER(Fa Iced ae only) <br /> 429 1998 UPGRADE CERTIFICATE NUMBER(Far Iwai a qtly) <br /> Is 1998 Compliant?Y <br /> UPCF(1/99 revised) <br />