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IFIED PROGRAM CONSOLIDATED FORM ! ,liil PR#:PR0231984 AFA #:FA0001393 UNDERGROUND STORAGE TANKS - FA TY 1 l � 63 4 (one pageper site) l/1 TYPE OF ACTION ❑ I.NEW SITE PERMIT ❑3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENTLY CLOSED SI 1 (Check one item only) ❑4.AMENDED PERMIT ❑ R.TANK REMOVED ❑ 6.TFNIPORARY SI TL CLOSII RI! q 1.FACILITY/SITE INFORMATION 890 N MAIN ST,MANTECA U U BUSINESS NAME(Sax.FACILITYNAMEwDBA-Domg Baamcas As) 3 FACILITYID# PR ID# MANTECA LIQUOR&FOOD FA0001393 PR0231984 NEAREST CROSS STREET FACILITY OWNER TYPE 401 ❑4.LOCAL AGENCY/DISTRICT- MAIN ❑ 1.CORPORATION ❑ 5.COUNTY AGENCY- BUSINESS ® 1.GAS STATION ❑ 3.FARM ❑ 5.COMMERCIAL ❑ 2.INDIVIDUAL El 6.STATE AGENCY- TYPE El 3.PARTNERSHIP IFS' 2.DISTRIBUTOR ❑4.PROCESSOR El 6.OTHER 4m ❑ 7.FEDERAL AGENCY' 402 TOTAL NUM BE TANKS Is facility on Indian Reservation or -if owner of UST is a public agency:name of supervisor of division,section or once which operates REMAINING AT SITE trustlands? the UST(This is the contact person for the tank records.) 4a ❑ Yes M No 405 MANTECA LIQUOR&FOOD 406 11.PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 002 PHONE 408 SANDHU GURENDERJEET S 209 825-5438 MATING OR STREET ADDRESS 409 2509 MOUNTAIN RIDGE DR CITY 410 STATE 411 ZIP CODE 012 MODESTO CA 95351 PROPERTY OWNER TYPE ® 1.CORPORATION ❑ 2.INDIVIDUAL [:14.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY ❑3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY 413 111.TANK OWNER INFORMATION TANK OWNER NAME 414 PHONE 415 SANDHU GURENDERJEET S MAILING OR STREET ADDRESS 41s 2509 MOUNTAIN RIDGE DR CITY 411 STATE418 ZIP CODE 419 MODESTO CA 95351 TANK OWNER TYPE ❑X 1.CORPORATION ❑2.INDIVIDUAL ❑ 4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY 420 ❑ 3.PARTNERSHIP ❑ 5.COUNTY AGENCY 1:17.FEDERAL AGENCY IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY(TK)HQ 44- 44-024950 1 Call(916)322-9669 if questions arise 4$1 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 1199.OTHER X❑3.INSURANCE ❑6.EXEMPTION ❑ 9.STATE FUND&CD 42 VI.LEGAL NOTIFICATION AND MAILING ADDRESS Check one box to indicate which address should be used for legal notifications and mailing. ® 1.FACILITY ❑2.PROPERTY OWNER ❑3.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 the information provided herein is we and accurate to the best ofmy knowledge.r SIGNATURE OF APPLICANT DATE 024 PHONE 425 NAME OF APPLICANT(print) 4, TITLE OF APPLICANT 427 STATE UST FACILITY NUMBER(For local ueamy) 428 1998 UPGRADE CERTIFICATE NUMBER(Forloal mcordy) 429 Is 1998 Compliant?Y UPCF(1/99 revised)