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IFIED PROGRAM CONSOLIDATED FOR* PR#:PR023106; <br /> F C#:F 00111909 <br /> UNDERGROUND STORAGE TANKS - FACILITC � � <br /> (one page per sitd� <br /> TYPE OF ACTION ❑ 1.NEW SITE PERMIT ❑ 3.RENEWAL PERMIT ❑ S.CHANGE OF INFORMATION ❑ 7.PERMANENTLY CLOSED SITE <br /> (Check one item only) ❑ 4.AMENDED PERMIT ❑ 8.TANK REMOVED <br /> ❑6.TEMPORARY SITE CLOSURE 400 <br /> I.FACILITY/SITE INFORMATION 1856 W COUNTRY CLUB BLVD.STOCKTON <br /> BUSINESS NAME(Same w FACBATY NAME or DBA-Doing Business As) g FACILITY Hl# PR ID# <br /> COUNTRY CLUB FOOD&FUEL MINI MART* FA0001909 PR0231069 <br /> NEAREST CROSS STREET FACILITY OWNER TYPE ❑4.LOCAL AGENCY/DISTRICT- <br /> 401 ® 1.CORPORATION <br /> ❑ 5.COUNTY AGENCY* <br /> BUSINESS ® 1 GAS STATION ❑ 3.FARM ❑ 5.COMMERCIAL ❑ 2.INDIVIDUAL ❑ 6.STATE AGENCY* <br /> TYPE ❑ 3PARTNERSHIP 402 <br /> ❑ 2.DISTRIBUTOR ❑4.PROCESSOR ❑ 6.OTHER 403 . ❑ 7.FEDERAL AGENCY* <br /> 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 <br /> REMAINING AT SITE trustlands? the UST(This is the contact person for the tank records.) <br /> 404 ❑ Yes ® No 405 406 <br /> II.PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408 <br /> ELDER FASSEL 209 662-0952 <br /> MAILING OR STREET ADDRESS 409 <br /> 4880 PEACH AVE <br /> CITY 410 1 STATE 411 ZIP CODE 412 <br /> MANTECA CA 95337 <br /> PROPERTY OWNER TYPE ❑ 1.CORPORATION ® 2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY <br /> ❑3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY 413 <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> KAUR SATWANT• SINGH HARPREET 209 462-0652 <br /> MAILING OR STREET ADDRESS 416 <br /> 1856 COUNTRY CLUB BLVD <br /> CITY 417 STATE 411 ZIP CODE 419 <br /> STOCKTON I CA 95204 <br /> TANK OWNER TYPE ❑ 1.CORPORATION ❑ 2.INDIVIDUAL 1:14.LOCAL AGENCY/DISTRICT 1:16.STATE AGENCY 420 <br /> ❑X 3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 44-024519 1 Call(916)322-9669 if questions arise 421 <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ❑ 1.SELF-INSURED ❑4.SURETY BOND ❑ 7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM <br /> ❑2.GUARANTEE ❑5.LETTER OF CREDIT X❑ 8.STATE FUND&CFO LETTER ❑99.OTHER <br /> ❑3.INSURANCE ❑6.EXEMPTION ❑ 9.STATE FUND&CD 422 <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one box to indicate which address should be used for legal notifications and mailing. ❑ 1.FACILITY ®2.PROPERTY OWNER ❑3.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 424 PHONE 425 <br /> (209)462-0652 <br /> NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 427 <br /> SATWANT KAUR OWNER <br /> STATE UST FACILITY NUMBER(For local ue only) 421 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 <br /> Is 1998 Compliant?Y <br /> UPCF(1/99 revised) <br />