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NIFIED PROGRAM CONSOLIDATED FOR11 PR0515864 0 A FFA0012355 UNDERGROUND STORAGE TANKS -FACIL T ..� Aageite l, TYPE OF ACTION 1.NEW SITE PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ '):`F RMANEN L LOSED SITE 'f1 (Check one item only) ❑ 4.AMENDED PERMIT ❑ 8.TANK REMO ED lJ ❑6.TEMPORARY SITE CLOSURE I� 400 1.FACILITY/SITE INFORMATION 1330 E YOSEMITE AVE.MANTECA BUSINESS NAME(Sarre as FACELMY NAME or DBA-Doing usiness As) 3 ILITY ID# PR ID# FA0012355 PRO515864 1 NEAREST CROSS STREET FACILITY OWNER TYPE ❑ 4.LOCAL AGENCY/DISTRICT-1.CORPORATION ❑ 5.COUNTY AGENCY* BUSINESS 1.GAS STATION ❑ 3.FARM ❑ 5.COMMERCIAL 2.INDIVIDUAL ❑ 6.STATE AGENCY* TYPE A ❑ 3.PARTNERSHIP 402 E] 2.DISTRIBUTOR E] 4.PROCESSOR ❑ 6.OTHER 403 ❑ 7.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 El Yes ® No aosI 1 a'a 11.PROPERTY OWNER INFORMATION PROPERTY OWNER NAME - 407 PHONE MAILING OR STREET ADD SS DR �4. ao9 CITY STATE 411 ZIP CODE �j atz PROPERTY OWNER TYPE I.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 � � J ata PHONE�� LS' - (;7.1 z- ats l� MAILING OR STREET ADDRESS 4 DR �dS e� I � , L,(- 416 CITY 417 7TATE 411 ZIP CODE 419 STU�N� 95279 TANK OWNER TYPE1.CORPORATION ❑ 2.INDIVIDUAL ❑ 4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY 420 ❑ 3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY(TK)HQ 44- 44-040767 1 Call(916)322-9669 if questions arise 421 V.PETROLEUM UST FINANCIAL RESPONSIBILITY INDICATE METHOD(s) ❑ 1.SELF-INSURED ❑4.SURETY BOND ❑ 7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM 1:12.GUARANTEE ❑ 5.LETTER OF CREDIT 8.STATE FUND&CFO LETTER ❑99.OTHER ❑3.INSURANCE ❑ 6.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. ® 1.FACILITY ❑2.PROPERTY OWNER ❑ 3.TANK OWNER 423 Legal notifications and mailing will be sent to the tank owner unless box 1 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. SIGNAT OF APPLICANT DATE 424 PHONE 425 7 22Z d E APPLICANT(print) 426 TITLE OF APPLICANT 427 4 C40-77'P STATE UST FACILITY NUMBER(For local ue only) 421 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 Is 1998 Compliant?Y UPCF(1/99 revised)