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'UNIFIED PROGRAM CONSOLIDATED FORS PR#:PRO23104 �qnI 1411110 AC#:FA0000717 UNDERGROUND STORAGE TANKS -FACILI 6im> Il�t��o3 TYPEOFACTION ❑ I.NEW SUE PERMIT ❑ 3.RENEWAL PERMIT 5_cl la,ll_a I'I N I I IHV:VlO, ❑ 7.PERMANENTLY CLOSED SITE (Check one item only) ❑4."ENDED PERMIT _peaty dwhx b Acernly '. ❑ 8.TANK REMOVED Elr. II NlvA2\KY ]II-nO,Im 400 1.FACILITY/SITE INFORMATION 1022 E FRONTAGE RD,RIPON BUSINESS NAME chat.FACILITY NAME oroeA-Doing,Business As) 3 FACILITY min PRID# JIMCO TRUCK PLAZA' FA0000717 PRO2316N NEAREST CROSS STREET FACILITY OWNER TYPE ❑4,LOCAL AGENCY/DISTRICT- 01 ❑ I.CORPORATION ❑ 5.COUNTY AGENCY' BUSINESS [:12.INDMDUAL Ell.GAS STATION ❑ 3.FARM ❑ S.COMMERCW. ❑ 3 PARTPARTNERSHIP ❑ 6.STATE AGENCY- 402TYPE E] 2.DISTRIBUTOR C]4.PROCESSOR E) 6.OTHER 4oa ❑ 7.FEDERAL AGENCY- TOTAL NUMBER OF TANKS Is facility on Indian Reservation or •Ifowner of UST is a public agency:name ofsupervisor ofdivision,section or office which coarses REMAINING AT SITE trustlands? the UST(This is the contact pawn for the tank mords.) 404 ❑ Yes ® No 405 HULNM DUNCAN 406 I1.PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407 PHONE 408 209 599-2112 MAILING OR STREET ADDRESS Boa 260 MICHELE CT CITY 410 1 STATE 411 ZIP CODE 412 S SAN FRANCISCO CA 94080 PROPERTY OWNER TYPE ® 1.CORPORATION ❑ 2.INDIVIDUAL ❑ 4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY ❑3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑7.FEDERAL AGENCY 413 II1.TANK OWNER INFORMATION TANKOWNERNAME 414 PHONE 415 OLYMPIA OIL CO 209 599-2112 MAILING OR STREET ADDRESS 416 260 MICHELE CT CITY 417 STATE Ola I ZIP CODE 419 S SAN FRANCISCO CA 94080 TANK OWNER TYPE © 1.CORPORATION ❑ 2.INDIVIDUAL ❑ 4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY 420 ❑ 3.PARTNERSHIP ❑ S.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 42' 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 (]99.OTHER ❑3.INSURANCE ❑6.EXEMPTION ❑ 9.STATE FUND&CD 423 VI.LEGAL NOTIFICATION AND MAILING ADDRESS Check one box to indicate which address should be used for legal notifications and mailing. ® 1.FACILITY ❑2.PROPERTY OWNER 113.TANK OWNER 423 Legal notifications and mailing will be sent to the sank owner unless box 1 or 2 is checked. VII.APPLICANT SIGNATURE Certification-1 certify that the infomlation provided herein is true and accurate to the best ofmy knowledge. SIGNATURE OF APPLICANT DATE 424 1 PHONE 425 NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 427 STATE UST FACILITY NUMBER(For lod ronly) 428 1998 UPGRADE CERTIFICATE NUMBER(Falomuse obs, 429 Is 1998 Compliant? UPCF(1/99 revised)