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� M <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (One page per site) Page] o1`5 <br /> TYPE OF ACTION ❑ L NEW PERMIT [13.RENEWAL PERMIT ®5.CHANGE OF INFORMATION ❑7.PERMANENTLY CLOSED SITE 400. <br /> (Check one item only) [14.AMENDED PERMIT (Specify change) ❑8.TANK REMOVED <br /> ❑6.TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3, 1 FACILITY <br /> Rai Gas Stations,Inc.,dba Yosemite 76 ID# 1 <br /> NEAREST CROSS STREET 401. FACILITY OWNER TYPE ❑4.LOCAL AGENCY/DISTRICT* 402. <br /> Highway 99 ® 1.CORPORATION [1'5.COUNTY AGENCY* <br /> BUSINESS® 1.GAS STATION ❑3.FARM [15.COMMERCIAL 403. ❑2.INDIVIDUAL [16.STATE AGENCY* <br /> TYPE ❑2.DISTRIBUTOR [14.PROCESSOR ❑6.OTHER ❑3.PARTNERSHIP ❑7.FEDERAL AGENCY* <br /> TOTAL NUMBER OF TANKS 404. Is facility on Indian Reservation 405. *If owner of UST is a public agency:name of supervisor of division,section or 406. <br /> REMAINING AT SITE or trust lands? office which operates the UST. (This is the contact person for the tank records.) <br /> 2 ❑Yes ®No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 408. <br /> Amar'it S.&Kashmir K.Rai (209)823-7676 <br /> MAILING OR STREET ADDRESS 409, <br /> 1700 E Yosemite Ave <br /> CITY 410. 1 STATE 411. ZIP CODE 412, <br /> Manteca CA 95336 <br /> PROPERTY OWNER TYPE 1.CORPORATION ®2.INDIVIDUAL 4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 413. <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415, <br /> Amar'it S.&Kashmir K.Rai (209)823-7676 <br /> MAILING OR STREET ADDRESS 416. <br /> 1700 E Yosemite Ave <br /> CITY 417. 1 STATE 418. ZIP CODE 419. <br /> Manteca CA 95336 <br /> TANK OWNER TYPE ❑ 1.CORPORATION ®2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 420. <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> IV. ARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 3 a 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 422 <br /> [12.GUARANTEE ❑5.LETTER OF CREDIT ®8.STATE FUND&CFO LETTER ❑99.OTHER: <br /> ❑3.INSURANCE ❑6.EXEMPTION ❑9.STATE FUND&CD <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one box to indicate which address should be used for legal notifications and mailing. <br /> Legal notifications and mailings will be sent to the tank owner unless box I or 2 is checked. ® ].FACILITY ❑2. PROPERTY OWNER ❑3.TANK OWNER 423. <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 APPLIC T DATE424. PHONE 425. <br /> i � S• L, y,/3� 0 6 ao9-y�s,aa913 <br /> NAME OF APPLICANT(p'nt) 426. TITLE OF APPLICANT 42T <br /> iTir <br /> STATE UST FACILITY NUMBER(Agency use only) 428. 1998 UPGRADE CERTIFICATE NUMBER(Agency use only) 429. <br /> (See Data Element 1,above. <br /> UPCF Hwfwrc-a(1/99)-1/2 http://www.unidocs.org Rev.02/16/00 <br />