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�FIED PROGRAM CONSOLIDATED FORM PR#: FA000 967 II I �C#:FA0003967 UNDERGROUND STORAGE TANKS -FACIL 'n[ pb /8! ( page pc VP one 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 ❑ 8.TANK REMOVED ❑6.TEMPORARY SITE CLOSURE 1 I.FACILITY/SITE INFORMATION 7644 N ASHLEY LN.STOCKTON h BUSINESS NAME(Samras FACILITY NAME MDBA-Doug Buninaa Aa) s FACILITY ID# PR ID# PACIFIC BELL FA0003967 PRO231872 NEAREST CROSS STREET 4m FACR-ITY OWNER TYPE ❑4.LOCAL AGENCY/DISTRICT• ASHLEY ❑ I.CORPORATION ❑ 5.COUNTY AGENCY' BUSINESS ❑ 2.INDIVIDUAL 6.STATE AGENCY• ® 1.GAS STATION ❑ 3.FARM ❑ 5.COMMERCIAL ❑ a02 TYPE ❑ 3.PARTNERSHIP is ❑2.DISTRIBUTOR ❑4.PROCESSOR ❑ 6.OTHER 45 [17.FEDERAL AGENCY- `11y/s7L TOTAL NI)MBER OF TANKS Is facility on Indian Reservation or 'If owns ofUST is a public agency:name ofsupervisor of division,section or office which operates REMAINING AT SITE [outlands? the UST(This is the contact person for the tank records.) ^\ a +04 ❑ Yes ® No 405 PACIFIC BELL 406 II.PROPERTY OWNER INFORMATION ��yy PROPERTY OWNER NAME w7 PHONE 4os Q'1 PACIFIC BELL ENVIRONMENTAL MGT 415 823-7777 \�yA MAILING OR STREET ADDRESS ao9 PO BOX 15038/3524 MARCONI RM B CITY 4111 STATE 411 ZIP CODE 412 SACRAMENTO CA 1 95851 PROPERTY OWNER TYPE ® I CORPORATION ❑ 2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY ❑3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY 415 III.TANK OWNER INFORMATION TANKOWNERNAME 414 PHONE 415 PACIFIC BELL ENVIRONMENTAL MGT 415 823-7777 MAILING OR STREET ADDRESS 416 PO BOX 15038/3524 MARCONI RM B CITY 417 STATE 419 ZIP CODE 419 SACRAMENTO CA 95851 TANK OWNER TYPE ❑X I.CORPORATION ❑ 2.INDIVIDUAL [14.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- 44-001027 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 ❑ 8.STATE FUND&CFO LETTER K❑99.OTHER ❑3.INSURANCE ❑6.EXEMPTION ❑ 9.STATE FUND&CD 4u VI.LEGAL NOTIFICATION AND MAILING ADDRESS Check one box to indicate which address should be used for legal notifications and maifing. ® 1.FACILITY ❑2.PROPERTY OWNER ❑3.TANK OWNER 4v 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 one and accurate w the best ofmy knowledge. SIGNATURE OF APPLICANT DATE 424 PHONE 425 NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 427 STATE UST FACILITY NUMBER(For moi m only) 428 1998 UPGRADE CERTIFICATE NUMBER(Fortool.only) 429 Is 1998 Compliant?Y UPCF(1/99 revised)