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aIFIED PROGRAM CONSOLIDATED FOPR #: PR0231404 111-7/0) FAC #: FAD002915 UNDERGROUND STORAGE TANKS - IF 11 (one page per site) TYPE OF ACTION ❑ I. NEW SITE PERMIT] 3.P ENEWAL PERMIT ❑ 5. CHANGE OF INFORMATION ❑ 7. PERMANENTLY CLOSED SITE (Check one item only) ❑ 4. AMENDED PERMIT all❑ 8. TANK REMOVED ❑ 6. TEMPORARY SITE CLOSURE 3 400 I. FACILITY / SITE INFORMATION 15 E GRANT LINE RD, TRACY BUSINESS NAME (Same as FACILITY NAME or DBA - Doing Business As) 3 FACILITY ID# PR 1D# BONFARE MARKET #35* FA0002915 PR0231404 1 NEAREST CROSS STREET FACILITY OWNER TYPE E]4. LOCAL AGENCYiDISTRICT* GRANT LINE 401 ❑ 1. CORPORATION ❑ 5. COUNTY AGENCY* ❑ 2. INDIVIDUAL ❑ 6. STATE AGENCY* BUSINESS N L GAS STATION ❑ 3. FARM ❑ 5. COMMERCIAL TYPE ❑ 2 DISTRIBUTOR ❑ 4. PROCESSOR ❑ 6. OTHER 403 ❑ 3. PARTNERSHIP ❑ 7. FEDERAL AGENCY* 402 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 aosBONFARE MARKETS INC 406 II. PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407 PHONE 408 SALLABERRY FAMILY TRUST MAILING OR STREET ADDRESS 409 1905 KRUBOR DR CITY 410 STATE 411 ZIP CODE 412 MODESTO CA 95355 PROPERTY OWNER TYPE ® 1. 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 414 PHONE 415 BONFARE MARKETS INC 510 732-5700 MAILING OR STREET ADDRESS 416 25064 VIKING ST CITY 417 STATE 418 ZIP CODE 419 HAYWARD 1 CA 194545 TANK OWNER TYPE 1. 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- 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 ❑ 2. GUARANTEE ❑ 5. LETTER OF CREDIT El 8. STATE FUND & CFO LETTER [9199. 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. N 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 - t certify that the information provided herein is true and accurate to the best of my knowledge. SIGNATURE OF APPLICANT DATE 424 PHONE 425 NAME OF APPLICANT (print) 426 TITLE OF APPLICANT 427 STATE UST FACILITY NUMBER (For local ue only) 428 1998 UPGRADE CERTIFICATE NUMBER (For local use only) 429 Is 1998 Compliant? Y 1 UPCF (1/99 revised)