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NIFIED PROGRAM CONSOLIDATED FOR* PR a:PR0231055 FAC#:FA0002321 UNDERGROUND STORAGE TANKS - FACILITY (one page per site) TYPE OF ACTION ❑ I.NEW SITE PERMIT ❑ 3.RENEWAL PERMIT5.CHANGE OF INFORMATION ❑ 7.PERMANENTLY CLOSED SITE (Check one item only) ❑ 4.AMENDED PERMIT Xwecify change local use only 8.TANK fEMOD ^ ❑6.TEMPORARY SITE CLOSU 3 S Zd U I.FACILITY/SITE INFORMATION 440 W CHARTER WAY,STOCKTON I R n� ilu BUSINESS NAME(Same as FACB.rrY NAME or DBA-Doing Busukss As) 3 FACILITY ID# PR ID# UNITED GAS FA0002321 PR0231055 NEAREST CROSS STREET FACILITY OWNER TYPE ❑4.LOCAL AGENCY/DISTRICT• CHARTER 401 M I.CORPORATION ❑ 5.COUNTY AGENCY* BUSINESS ❑ I.GAS STATION ❑3.FARM ❑ 5.COMMERCIAL ❑2.INDIVIDUAL ❑6.STATE AGENCY' TYPE E] 2. E] ED 3.PARTNERSHIP 402 2.DISTRIBUTOR 4.PROCESSOR 6.OTHER 403 ❑ 7.FEDERAL AGENCY- TOTAL NUMBER OF TANKSIs facility on Indian Reservation or 01fowner 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 407 PHONE 408 209 833-6427 MAILING OR STREET ADDRESS 409 PO BOX 1136 CITY 410 STATE 411 ZIP CODE 41 TRACY CA 95378 PROPERTY OWNER TYPE IN 1.CORPORATION ❑ 2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY ❑3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY 41l III.TANK OWNER INFORMATION TANK OWNER NAME 414 PHONE 415 GILL,JODHA (209)833-6427 MAILING OR STREET ADDRESS 416 PO BOX 1136 CITY 417 1 STATE 418 1 ZIP CODE 419 TRACY CA 95378 TANK OWNER TYPE ❑R 1.CORPORATION ❑ 2.INDIVIDUAL 114.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 420 ❑ 3.PARTNERSHIP 115.COUNTY AGENCY ❑ 7.FEDERAL AGENCY TANK OPERATOR INFORMATION TANK OPERATOR NAME TANK OPERATOR TITLE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY(TK)HQ 44- 1 44-039026 1 Call(916)322-9669 if questions arise 411 V.PETROLEUM UST FINANCIAL RESPONSIBILITY INDICATE METHOD(s) ❑ 1.SELF-INSURED ❑4.SURETY BOND ❑ 7.STATE FUND ❑ lo.LOCAL GOVT MECHANISM 1:12.GUARANTEE ❑5.LETTER OF CREDIT ❑ 8.STATE FUND&CFO LETTER ®99.OTHER ❑3.INSURANCE 116.EXEMPTION ❑ 9.STATE FUND&CD 422 VI.LEGAL NOTIFICATION AND MAILING ADDRESS Check one box to indicate which address should be used for legal notifications and mailing. ,X 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. LJ 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 424 r HONE 4's NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 117 STATE UST FACILITY NUMBER(For local ue only) 428 1 1998 UPGRADE CERTIFICATE NUMBER(For loaf use only) 429 Is 1998 Compliant?Y UPCF(1/99 revised)