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• �IFIED PROGRAM CONSOLIDATED FORM* PR #: PR0231482 FAC #: FA0000720 UNDERGROUND STORAGE TANKS - FACILIg5L!�/q 9�",) �1 (one page per si TYPE OF ACTION ❑ I. NEW SITE PERMIT 3. RENEWAL PERMIT ❑ 5. CHANGE OF INFORMATION ❑ 7. PERMANENTLY CLOSED SITE (Check one item only) 4. AMENDED PERMIT NOMMENNEIRRM❑ 8. TANK REMOVED ❑ 6. TEMPORARY SITE CLOSURE 400 I. FACILITY / SITE INFORMATION 239 S STOCKTON ST, RIPON BUSINESS NAME(Sawn FACILDYNA mDBA-Doing emb,®e As) 3 FACILITYID# PR ID" MADSENS SUNRISE DAIRY FA0000720 I PR0231482 NEAREST CROSS STREET FACILITY OWNER TYPE GENCY/DISTR CT" El 4. LOCAL AGENCY/DISTRICT- STOCKTON 401 STOCKTON ❑ 1. CORPORATION El S. COUNTY AGENCY" � INDIVIDUAL El 6. STATE AGENCY" BUSINESS ry 1' GAS STATION ❑ 3. FARM ❑ 5. COMMERCIAL W TYPE ❑ 2. DISTRIBUTOR ❑ 4. PROCESSOR ❑ 6. OTHER 403 3. ❑ 3. PARTNERSHIP El 7. FEDERAL AGENCY" 402 TOTAL NUMBER OF TANKS IN REMAING AT SITE Is facility on Indian Reservation or trustlands? *(owner of UST is a public agency: name ofsupervisor ofdivision, section or office which operates p the UST (This is the context person for the tank records.) 404 ❑ Yes ® No ops 406 R. PROPERTY OWNER INFORMATION PROPERTY OWNER NAME a01 PHONE yG& E Ra rn�s l a�4 s 46 MAHJNG OR STREET ADDRESS 409 239 S STOCKTON CITY 410 STATE411 ZIP CODE 412 RIPON CA 95366 PROPERTY OWNER TYPE . CORPORATION 2. INDIVIDUAL [14. LOCAL AGENCY / DISTRICT ❑ 6. STATE AGENCY [:13. PARTNERSHIP ❑ 5. COUNTY AGENCY ❑ 7. FEDERAL AGENCY 413 III. TANK OWNER INFORMATION TANK OWNER NAME 414 PHONE5 J J 3 / i `i 415 ,/ V MADSEN ROBERT & CAROL 1 1 MAILING OR STREET ADDRESS 416 239 S STOCKTON CITY 417 STATE 418 ZIP CODE 019 RIPON 1 CA 95366 TANK OWNER TYPE ffl 1. CORPORATION 1% 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- 44-020313 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. CUARANfEE 1:15. 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 notificaficns and mailing. ® L FACILITY ❑ 2. PROPERTY OWNER ❑ 3. TANK OWNER 423 Legal cations and mailing will be sent to the tank owner unless box 1 or 2 is checked. VII. APPLICANT SIGNATURE ni lion- I certify that the information provided herein is me and accurate to the best ofmy knowledge. Si TO OF PUCANT DATE 424 PHON 425 �5• z -o 3 N OF APPLICANT pant) 426 TITLE OF APPLICANT 429 STATE UST FACILITY NUMBER(Forloralony) 428 1998 UPGRADE CERTIFICATE NUMEER(For Imal ter arty) 429 Is 1998 Compliant? Y UPCF (1/99 revised)