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_ f <br /> U r D PROGRAM CONSOLIDATED FORM OR 0,ry7lt�y4 <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (One page per Site) Page_of <br /> TYPE OF ACTION ❑1.NEW PERMIT ❑3.RENEWAL PERMIT ❑5.CHANGE OF INFORMATION ❑7.PERMANENTLY CLOSED SITE 400. <br /> (Check one item only) ❑4.AMENDED PERMIT(Specify change) ®8.TANK REMOVED <br /> ❑6.TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION <br /> BUSINESS NAM E(S. .m FACILITY NAME or DBA-Doi,Business A.) 3. 1 FACILITY <br /> SANGUINETTI FARMINGTON IDp <br /> NEAREST CROSS STREET 4o1. FACILITY OWNER TYPE ❑4.LOCAL AGENCY/DISTRICT' 402 <br /> ESCALON BELLOTA ROAD ®1.CORPORATION ❑5.COUNTY AGENCY- <br /> BUSINESS®1.GAS STATION 0 3.FARM 5.COMMERCIAL 403 ❑2.INDIVIDUAL ❑6.STATE AGENCY* <br /> TYPE [12.DISTRIBUTOR ❑4.PROCESSOR ❑6.OTHER ❑3.PARTNERSHIP ❑7.FEDERAL AGENCY' <br /> TOTAL NUMBER OF TANKS 404 Is facility on Indian Reservation 405. "If owner of UST is a public agency:tame of supervisor of division,section or 406. <br /> REMAINING AT SITE or trust lands? office which operates the UST. (This is the contact person for the am,records.) <br /> ZERO ❑Yes ®No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE eros. <br /> SANGUINETTI INVESTMENTS 209-607-9229 <br /> MAILING OR STREET ADDRESS 4a9. <br /> 18638 E.COPPEROPOLIS ROAD <br /> CITY 410. 1 STATE 411. ZIP CODE 412. <br /> LINDEN CA 95231 <br /> PROPERTY OWNER TYPE 1.CORPORATION 2.INDIVIDUAL U 4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 413. <br /> [13.PARTNERSHIP [15.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415, <br /> SANGUINETTI INVESTMENTS <br /> MAILING OR STREET ADDRESS 416. <br /> 18638 E.COPPEROPOLIS ROAD <br /> CITY 417. STATE 418. ZIP CODE 419. <br /> LINDEN CA 95231 <br /> TANK OWNER TYPE ® 1.CORPORATION ❑2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 420. <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY [17.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY K HQ 44 1 1 1 1 1 1 1 Call 916 322-9669 if questions arise 421. <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ®1.SELF-INSURED ❑4.SURETY BOND ❑7.STATE FUND ❑10.LOCAL GOVT MECHANISM 422 <br /> ❑2.GUARANTEE ❑5.LETTER OF CREDIT ❑8.STATE FUND&CFO LETTER ❑99.OTHER. <br /> ❑3.INSURANCE ❑6.EXEMPTION [19.STATE FUND&CD <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one box to indicate which address should be used for legal notifications and wiling. <br /> Legal notifications and mailings will be sant to the tack owner unless box I or 2 is checked ❑ 1.FACILITY ®2. PROPERTY OWNER ❑3.TANK OWNER 423. <br /> VII.APPLICANT SIGNATURE <br /> Cecfifica that the inf 'on provi heroin is ave and ac w to to the best of my knowledge. <br /> SIGNA PLIC DATE 424. PHONE 425. <br /> 25 MAY 2006 209 467-1006 <br /> N F APPLICANT(print) 426. TITLE OF APPLICANT 427. <br /> CHRISTOPHER R.MILLER AGENT FOR OWNER <br /> STATE UST FACILITY NUMBER(AS•ncywe only) 438. 1998 UPGRADE CERTIFICATE NUMBER(As."w vsly) 429. <br /> (See Data Element 1,above. <br /> UPCF Hwfwrc-a(1/99)-1/2 bttp://www.unidocs.org Rev.02/16/00 <br />