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03/07/2008 13:03 FAX 19257561227 QUEST GSM 1jt002 <br /> 44 1 <br /> UNIFIED PROGRAM CONSOLIDATED FORM V <br /> TANKS <br /> E: <br /> UNDERGROUND STORAGE TANKS -FACILITY(One page per site) Page I of S <br /> TYPE OF ACTION 13 1.NEW PERMIT [3 3.RENEWAL PERMIT 5.CHANGE OF INFORMATION ❑7.PERMANENTLY CLOSED SITE 400. <br /> (Check one item only) [3 4.AMENDED PERMIT (Specify change) ❑8.TANK REMOVED <br /> 0 6.TEMPORARY SITE CLOSURE <br /> ki. <br /> ImR1 H <br /> BUSINESS NA (Sainew FACILMY NAMrorI)I1A-DoingRusinwAS) 3. rFACILITY <br /> D# 7 <br /> Statewide Petroleum Inc,dba Yosemite 76 ID# <br /> NFAREST CROSS STREET 4o1. FACE L-ITYOWNER TYPE C]4.LOCAL AGENCY/I)ISTRICT* 402. <br /> Highway 99 0 1.CORPORATION []5.COUNTY AGENCY* <br /> BUSINESS P9 1.GAS STATION El 3.FARM [15.COMMERCIAL 03- ❑2.INDIVIDUAL Ej 6.STATE AGENCY* <br /> TYPE []2.DISTRIBUTOR D 4.PROCESSOR El 6.OTHER ❑3.PARTNERSHIP [:17.FEDERAL AGENCY* <br /> TOTAL NUMBER OF TANKS 404. 16 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 took records) <br /> 2 0 Yes ®No H %%, i.mmoL ow <br /> P , <br /> F --mg .�!-- <br /> M <br /> 2� <br /> 4, !PIP <br /> %OEM WIN <br /> PROPERTY OWNER NAME 407. PHONE 408. <br /> Statewide Petroleum,Inc. (408)230-8999 <br /> MAILING OR STREET ADDRESS 09. <br /> 1700 E.Yosemite Avenue <br /> CITY 410. STATE 4117f-MP CODE 412. <br /> Manteca CA 1 95336 <br /> AL [14.LOCAL AGENCY/DISTRICT 6.STATE AGENCY <br /> PROPERTY OWNER TYPE 0 1.CORPORATION INDIVIDUAL 413. <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> Li <br /> L W, <br /> im <br /> I, "JIMN1,111=111, <br /> WWI <br /> TANK OWNER NAME A 414. PHONE 415. <br /> Statewide PetroleuM Inc. (209)823-7676 <br /> MAILING OR STREET ADDRESS 416. <br /> 1700 E.Yosemite Avenue <br /> CITY 417. STATE ms. ZIPCODF- 419. <br /> Manteca I CA 95336 <br /> TANK OWNER TYPE 1.CORPORATION 2.INDIVIDUAL Lj 4.LOCAL AGENCY/DISTRICT 6.STATE AGENCY 420. <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> i-ruup:, <br /> 00 <br /> fig <br /> H44- C r <br /> TY TK C,11 Q16)322-9669 if%!estiotis arise 421. <br /> 9 <br /> Voll I'M N W. ,I <br /> is' pin, I'Lliff M. <br /> -M- Mom N-01=4111 1101.0, <br /> INDICATE METHOD(s) [3 1.SELF-INSURED [3 4.SURETY BOND (3 7.STATE FUND [3 10.LOCAL GOVT MECHANISM 422. <br /> L3 2.GUARANTEE Ll 5.LETTER OF CREDIT 99 S.STATE FUND&CPO LETTER Q 99.OTHER: <br /> []3.INSURANCI3 L]6.EXEMPTION 0 9.STATE FUND&CD <br /> ,rr;.4 F, !1114 fill, .1 IM9 <br /> il-;W -M-1 Ila <br /> i,JrAie <br /> R.= <br /> Check else box to indicate which add es should be used for legal notifications and mailing. <br /> Legal notifications and mailings will be ant to the tank owner unless box I or 2 is chocked. I.FACILITY ❑2. PROPERTY OWNER C1 3.TANK OWNER 423- <br /> rz <br /> i�i�kfiffi <br /> Uq; -Hmpr <br /> MOM h <br /> Certification: I certify that the inibmustion provided herein is true and accurate to the best of my knowledge. <br /> SIGNATURE OF APPLICANT DATE 424. PHONE 425. <br /> c- <br /> cl KIR <br /> NAME OF APPLICANT(pritit) "PPLICANT 427. <br /> 4- <br /> > L, A "I -T�A�-k r-Q-J, <br /> STATE UST FACILITY NUMBER(Agency use only) 428. 1998 UPGRADE CERTIFICATE NUMBER(Agony ustonly) 429. <br /> (See Data Element 1,above. I <br /> UPCF Hwfwre-a(1/99)-1/2 btip://www.unidoes.org Rev.02/16t00 <br />