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NIFIED PROGRAM CONSOLIDATED FOR* PR #: PR <br />PR( <br />FAC #: • A�% <br />12�r� 5 <br />UNDERGROUND STORAGE TANKS - FACILITY <br />one page pet si (�Fy <br />TYPE OF ACTION ❑ 1. NEW SITE PERMIT 3. RENEWAL PERMIT ❑ 5. CHANGE OF INFORMATION ❑ 7. PERMANENTLY CW.5ED SrrI1 �/- <br />(Check one item only) C ' <br />❑ 4. AMENDED PERMIT ❑ S. TANK REMOVED 1r,�•� - <br />❑ 6. TEMPORARY SITE CLOSURE t ...;�,;,. 400 <br />I. FACILITY / SITE INFORMATION 2771 E FRENCH CAMP RD, MANTECA <br />BUSINESS NAME (Same as FACILITY NAME or DBA - Doing Business As) 3 <br />FACILITY ID# <br />PR ID# <br />ACE TOMATO CO INC <br />FA0003508 <br />PR0234251 <br />NEAREST CROSS STREET 401 <br />FACILITY OWNER TYPE ❑ 4. LOCAL AGENCYi&RICTn ]7S <br />FRENCH CAMP <br />❑ 1. CORPORATION ❑ 5. COUNTY AGENCj' - <br />❑ 2. INDIVIDUAL ❑ 6. STATE AGENCY - <br />BUSINESS ❑ 1, GAS STATION ❑ 3. FARM ❑ 5. COMMERCIAL <br />TYPE <br />❑ 2. DISTRIBUTOR ❑ 4. PROCESSOR ❑ 6. OTHER 403 <br />❑ 3. PARTNERSHIP 402 <br />❑ 7. FEDERAL AGENCY" <br />TOTAL NUMBER OF TANKS <br />Is facility on Indian Reservation or <br />"If owner of UST is a public agency: name of supervisor of division, section or office which operates <br />REMAINING AT SITE <br />trustlands? <br />the UST (This is the contact person for the tank records.) <br />404 <br />❑Yes ®No 405 <br />ACE TOMATO CO INC 406 <br />II. PROPERTY OWNER INFORMATION <br />PROPERT OWNER NAME 407 <br />1N <br />PHONE 408 <br />f E -'f 1 G, <br />209 478-7142 <br />MAILING OR STREET ADDRESS 409 <br />2771 E FRENCH CAMP RD <br />CITY 410 <br />STATE 411 <br />ZIP CODE 412 <br />MANTECA <br />CA <br />95336 <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 <br />PHONE 415 <br />ACE TOMATO CO INC <br />209 478-7142 <br />MAILING OR STREET ADDRESS 416 <br />2771 E FRENCH CAMP RD <br />CITY 417 <br />STATE 411 <br />ZIP CODE 419 <br />MANTECA <br />CA <br />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. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br />TY (TK) HQ 44- 44-025075 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 ❑ 8. STATE FUND & CFO LETTER ❑X 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 I 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 />SIGNAT�PLI ANT <br />DATE aza <br />7 /63 <br />PHONE 425 <br />�I- <br />NAME OF APP T (print) 426 <br />TITLE OF APPLICAN 427 <br />UST FACILITY NUMBER ( local ue only) 428 <br />r <br />1998 UPGRADE CERTIFICATE NUMBER (For local use only) 429 <br />Is 1998 Compliant? Y <br />UPCF (1/99 revised) <br />D <br />403 <br />