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ITN' '.D PROGRAM CONSOLIDATED FORM <br /> TANKS �ftw <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (One page per site) Page 1 of 3 <br /> TYPE OF ACTION ❑ 1.NEW PERMIT ❑3.RENEWAL PERMIT ❑5.CHANGE OF INFORMATION ❑7.PERMANENTLY CLOSED SITE 400. <br /> (Check are item only) ❑4.AMENDED PERMIT (Specify change) ®8.TANK REMOVED <br /> [16.TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Sena®PACIUTY NAaB or DBA-notes Baimr AS) 3. 1 FACILITY I .: <br /> SBC SKTNCAI2 UE132 ID# 1 <br /> NEAREST CROSS STREET 401. FACILITY OWNER TYPE Lj 4.LOCAL AGENCY/DISTRICT' 402, <br /> FOPPIANO LANE ® 1.CORPORATION ❑S.COUNTY AGENCY' <br /> BUSINESS 1.GAS STATION U 3.FARM Ej 5.COMMERCIAL 403. [12.INDIVIDUAL Ll 6_STATE AGENCY' <br /> TYPE [12.DISTRIBUTOR 1-14.PROCESSOR ®6.OTHER [13,PARTNERSHIP [17.FEDERAL AGENCY* <br /> TOTAL NUMBER OF TANKS 404. IS facility on Indian Reservation 405 'If owner of UST is u public agctay: ism:of supervisor of division, action or 406. <br /> REMAINING AT SITE or trust lands? office which operates the UST. (TMs is the contact person ibr the tank mcmdaJ <br /> 0 ❑Ycs ®No <br /> H. PROPER"L"Y SJWNERINFORMATION <br /> PROPERTY OWNER NAME 407 1 PHONE 408, <br /> SBC 132 SKTNCAI2 800-757-6575 <br /> MAILING OR STREET ADDRESS 4a9 <br /> 7644 N.ASHLEY LANE <br /> CITY 410. 1 STATE an. ZIP CODE 412. <br /> STOCKTON CA 95212 <br /> PROPERTY OWNER TYPE ® LCORPORATION 2.INDIVIDUAL 4.LOCAL AGENCY/DISTRICT 6.STATE AGENCY na. <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> M. TANK OWNER INFORMATION <br /> TANKOWNERNAME 414. PHONE 415. <br /> SBC ENVIROMENTAL MANAGEMENT 800-757-6575 <br /> <1s. <br /> MAILING OR STREET ADDRESS <br /> PO BOX 5095,ROOM 3E000 <br /> CITY Ott STATE us, ZIP CODE 419. <br /> SAN RAMON CA 94583-0995 <br /> TANKOWNER TYPE N 1.CORPORATION 2.INDMDUAL El 4.LOCAL AGENCY/DISTRICT U&STATEACIENCY 420, <br /> ❑3.PARTNERSHIP [15 COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY HQ 44- 1 3 1 1 1 9 1 1 4 1 1 Call 916 322-9669 if questiong arise 421. <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ®1.SELF-INSURED ❑4.SURETY BOND ❑7.STATE FUND ❑10.LOCAL GOV"f MECHANISM 423 <br /> ❑2.GUARANTEE ❑5.LETTER OF CREDIT ❑8.STATE FUND&CFO LEITER ❑99.OTHER: <br /> ❑3.INSURANCE [16.EXEMPTION [19,STATE FUND&CD <br /> VI. LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Chock one boz N irdicak which 9ddmae elwuld be uad for legal notifieatimu and nailing. <br /> Legal m6ficatiens and mailings will be sent to flit tank owner unless box I or 2 is checked. ❑ 1.FACILITY ❑2. PROPERTY OWNER X 3.TANK OWNER 473. <br /> VD. APPLICANT SIGNATURE <br /> Certification: I certify that an:information provided heroin is true and accurate to the beet of my knowledge. <br /> SIGNATUaEO APPLICANTDATE 424. PHONE 42s. <br /> 77 - <br /> 5/02/03 800-757-6575 <br /> NAME O PPUCANT(print) 428' TITLE OF APPLICANT 427' <br /> ANDREW TAYLOR ENVIRONMENTAL MANAGER <br /> STATE UST FACILITY NUMBER(Atmev neo^^lr1 428. 1998 UPGRADE CERTIFICATE NUMBER(Agra y ae on1y) 419' <br /> (See Delta Element 1.above. <br /> UPCF Hwfwrew(1/99)-1/2 http://www.unidues.org Rev.02/16/00 <br /> RECEIVED FEB-11-04 15:09 FROM-9168581011 TOALEEMAN ROEBBELEN PAGE 16 <br />