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NIFIED PKUCONSOLIDATED FORK PR#:PR0231 \a I0101 FAC#:FA0006M 0!UNDERGROUND STORAGE TANKS - FACILITY W NN .ja: h) It_6,0'1 TYPE OF ACTION ❑ I.NEWSITE PERMIT ❑3.RENEWAL PERMIT ❑ 5.CIIANGEOFINI'ORMATION ❑ 7.PERMANENTLY CLOSED SITE (Check one item only) ❑4,AMENDED PERMIT speeifychangclaameady ❑ S.TANKREMOVED ❑ 6.1 LMPORARY SITE CLOSURE a00 1.FACILITY/SITE INFORMATION 1022 E FRONTAGE RD,RIPON BUSINESSNAME(s uFAcarrY mDm-Dokq Buivms As) 3 FACILITY ID# PR IDN JUACO TRUCK PLAZA; FA0000650 PRO231604 NEAREST CROSS STREET mI FACILITY OWNER TYPE ❑4.LOCAL AGENCY/DISTRICfa ® I.CORPORATION ❑ S.COUNTY AGENCY' BUSINESS ❑ L GAS STATION ❑ 3.FARM ❑5.COMMERCIAL ❑ 2.INDIVIDUAL ❑ 6.STATE AGENCY- TYPE ❑ 2.DISTRIBUTOR ❑4.PROCESSOR ❑ 6.OTHER 403 ❑3.PARTNERSHIP ❑ 7.FEDERAL AGENCY' TOTAL NUMBER OF TANKS Is facility on Indian Reservation or elf owner of UST is a public agency:name of supervisor ofdivisio t,section or office which operates REMAINING AT SITE truatlands? Ne UST(This is the contact pawn for the tank records.) 404 ❑ Yes ®No 408 404 IL PROPERTY OWNER INFORMATION PROPERTY OWNER NA aoI PHONI LOSS S`1 L-S-i 50 MI8 bulP&rIA�J bt` CA, 2 l01 MARLING OR STREET ADDRESS 409 469._� 17,13D ZNDu�TQ � R 9• S'�E. 1� CITY SAS 4Io STATE 411ZIP CODE q��O 412 CA 94689 PROPERTY OWNER TYPE M I CORPORATION ❑ 2.INDIVIDUAL ❑ 4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY [-13.PARTNERSHMP ❑5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY 413 ILL TANK OWNER INFORMATION TANK OWNER NAME 411PHONE Bd - G-Gfrb� OLYMPIA OIL CO MAILING OR STREET ADDRESS 416 -yam 13 u v T I�O�ASTR A1_ F-0 • STE . 2 CITY 417STATE 418 ZIP CODE 419 SgaJ LfkR l OS CA A6080 4 L10-) C) TANK OWNER TYPE ❑X L CORPORATION ❑ 2.INDIVIDUAL ❑ 4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY 420 [-13,PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY(TK)HQ 44- 44-024783 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 MECHAMSM ❑2.GUARANTEE ❑5.LETTER OF CREDIT ❑ 8.STATE FUND&CFD LETTER CU 99.OTHER ❑3.INSURANCE ❑6.EXEMPTION ❑ 9.STATE FUND&CD 4n VI.LEGAL NOTIFICATION AND MAILING ADDRESS Check one box to contents which address should be used for legal notifications and mailing. ❑ L FACILITY M 2.PROPERTY OWNER ❑3.TANK OWNER 423 Legal notifications and mailing will be sent to the unk owner unless box 1 or 2 is checked. VII-APPLICANT SIGNATURE Certification-1 certify that the information provided herein is true and accmau to the best of my knowledge. SIGNATURE OF APPLICANT DATE 424 1 PHONE 415 NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 27 STATE UST FACILITY NUMBER(Fer Ioa1uemdy) 428 1998 UPGRADE CERTIFICATE NUMBER(F«Loa uwe ,) 429 Is 1998 Compliant? UPCF(1/99 revised)