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• 0IFIED PROGRAM CONSOLIDATED FORT f PR#:PR023'1464 ' FAC#:FA0000914 UNDERGROUND STORAGE TANKS -FACILITY Dr �A (one page per site) TYPE OF ACTION ❑ 1.NEW SITE PERMIT ❑ 3.RENEWAL PERMIT 5.CHANGE OF INFORMATION ❑ 7.PERMANENTLY CLOSED SITE (Check one item only) ❑ 4.AMENDED PERMIT E] S.TANK REMOVED ❑6.TEMPORARY SITE CLOSURE 400 I.FACILITY/SITE INFORMATION 1399 E YOSEMITE AVE,MANTECA BUSINESS NAME(same as FAaLrrY NAME or DBA-Doing Business As) 3 FACILITY ID# PR ID# TIGER EXPRESS STORES FA0000914 PR0231464 l NEAREST CROSS STREET FACILITY OWNER TYPE ❑4.LOCAL AGENCY/DISTRICT- YOSEMITE 401 ❑ 1.CORPORATION ❑ 5.COUNTY AGENCY' BUSINESS ❑ 1.GAS STATION ❑3.FARM p 5.COMMERCIAL ❑ 2.INDIVIDUAL ❑ 6.STATE AGENCY' TYPE [j 3.PARTNERSHIP 402 ❑2.DISTRIBUTOR ❑4.PROCESSOR ❑ 6.OTHER 403 El7.FEDERAL AGENCY* TOTAL NUMBER OF TANKS Is facility on Indian Reservation or If owner of UST is a public agency:name of supervisor of division,section or office which operates REMAINING AT SITE trustlands? the UST(This is the contact person for the tank records.) 404 ❑ Yes ®No 405 406 II.PROPERTY OWNER INFORMATION PROPERTY OWNER NAME U-C 407 PHONE 2041- 2- 37 Z aos G ALS cf?Nt A C,AS S-A ri3ON MAILING OR STREET ADDRESS /� T -L Q 409 nn 9 nv t�rl7 A O W' f?AN l -t� 1� CITY 411STATE all ZIP CODE 412 �A c� CA - °f 5 3 6 PROPERTY OWNER TYPE ® 1.CORPORATION ❑ 2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY ❑3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY 413 III.TANK OWNER INFORMATION TANK OWNER NAME ala PHONE(.: p.oq) 32. T372 415 c�ciFbRrttA �<tS 56 ATl" L -- MAILING OR STREET ADDRESS 416 Pe-nex`r2ur A M E CITY at7 STATE alg ZIP CODE 419 5� 3q_ 5 ^'I E CA lv5M7 0.5376 TANK 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 STO OUNT NUMBER TY(TK)HQ 44- •9a}q,T$4• Call(916)322-9669 if uestions arise 421 V.PETROLEUM UST FINAN SP TY INDICATE METHOD(s) ❑ 1.SELF-INSURED 1:14.SURETY BOND ❑ 7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM ❑2.GUARANTEE 1:15.LETTER OF CREDIT a) 8.STATE FUND&CFO LETTER (]99.OTHER ❑3.INSURANCE 1:16.EXEMPTION ❑ 9.STATE FUND&CD 4222 VI.LEGAL NOTIFICATION AND MAILING ADDRESS Check one box to indicate which address should be used for legal notifications and mailing. ®' 1.FACILITY 2.PROPERTY OWNER ❑3.TANK OWNER 423 Legal notifications and mailing will be sent to the tank owner unless box I or 2 is checked. VII.APPLICANT SIGNATURE Certification-I certify that the information provided herein is true and accurate to the best of my knowledge. SIGNATURE OF APPLICANT DATE ata PHONE 425 Roo, s. �--1$- 1 -2 0 5- $32 - 2- NAME OF APPLICANT(print) 426 TITLE OF APPLICANT a,; S t 457N/%NHRS 1-?l.1 rjVCR o w.✓ei? STATE UST FACILITY NUMBER(For local ue only) 428 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 420 Is 1998 Compliant?Y UPCF(1/99 revised)