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UNIFIED PROGRAM CONSOLIDATED FORM PRH:PRO231528 <br /> FAC H:FAO <br /> UNDERGROUND STORAGE TANKS -FACILITY <br /> (one page per site) <br /> J <br /> TYPE OF ACTION ❑ LNEWSITEPERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CIIANGE OF[NFORMATIO] ❑ 7.PERMANENTLY CLOSED SITE t1 <br /> (Check one item only) ❑4.AMENDED PERMIT spodry then,,b n only. ❑ 8.TANK REMOVEDA <br /> 1 <br /> ❑6.TEMPORARY Sri F CLOSI IRF <br /> 1.FACILITY/SITE INFORMATION 24124 N BRUELLA RD,ACAMPO <br /> BUSINESS NAME(Suneas FACILITYNMJEm DBA-Doiasam.as As) 3 FACILITY IDH PR IDN <br /> LIBERTY RURAL FIRE DISTRICT FA0003795 PR0231528 <br /> NEAREST CROSS STREET w FACILITY OWNER TYPE ❑ C LOCAL AGENCYIDISTRICT' <br /> BRUELLA RD ❑ 1.CORPORATION ❑ 5.COUNTY AGENCY' <br /> BUSINESS ® ❑ 2.INDIVIDUAL <br /> ].GAS STATION ❑ 1.FARM ❑ 5.COMMERCIAL ❑ 6.STATE AGENCY' <br /> TYPE ❑2.DISTRIBUTOR ❑ 4.PROCESSOR ❑ 6.OTHER w3 ❑3.PARTNERSHIP ❑ 7.FEDERAL AGENCY' 402 <br /> TOTAL NUMBER OFTANKS Is facility on Indian Reservation or 'Ifowner of UST is a public agency:name of supervisor ofdivision,section or office which operates <br /> REMAINING AT SITE nostlands? the UST(This is the contact person for the tank records.) <br /> 4n4 ❑ Yes ® No 405 LIBERTY RURAL FIRE DISTRI A06 <br /> 11.PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME wr PHONE 408 <br /> LIBERTY RURAL FIRE DISTRICT 209 368-0905 <br /> MARLING OR STREET ADDRESS 409 <br /> Same As Site <br /> CITY 410 STATE 411 ZIP CODE 412 <br /> Satin As Site Same As Site Same As Site <br /> PROPERTY OWNER TYPE ❑ I.CORPORATION ❑ 2.INDIVIDUAL ❑ 4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY <br /> ❑3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY 413 <br /> 111.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> LIBERTY RURAL FIRE DISTRICT 209 368-0905 <br /> MAILING OR STREET ADDRESS 416 <br /> 24124 N BRUELLA RD <br /> CITY 417 STATE 418 ZIPCODE 419 <br /> Same As Site Same As Site Same As Site <br /> TANK OWNER TYPE ❑ L CORPORATION ❑ 2.INDIVIDUAL ❑ 4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY 420 <br /> ❑ 3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 44-024739 1 Call(916)322-9669 if questions arise 431 <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ❑ 1.SELF-INSURED ❑4.SURETY BOND ❑ 7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM <br /> ❑2.GUARANTEE ❑ 5.LETTER OF CREDIT ❑ 8.STATE FUND&CFO LETTER 99.OTHER <br /> ❑3.INSURANCE ❑6.EXEMPTION ❑ 9.STATE FUND&CD J12 <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one box to indicate which address should be used for legal notifications and mailing ® 1.FACILITY ❑2.PROPERTY OWNER ❑3.TANK OWNER 423 <br /> Legal notifications and mailing will be sent to the tank owner unless box 1 or 2 is checked. <br /> VII.APPLICANT SIGNATURE <br /> Certification-I certify that the information provided herein is tine and accurate to the best ofmy knowledge. <br /> SIGNATURE OF APPLICANT DATE 424 1 PHONE 425 <br /> NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 427 <br /> -j <br /> STATE USTFACILITYNUMBER(FrcI .I..nly) 428 1998 UPGRADE CERTIFICATE NUMBER(Foct al meealy) 429 <br /> Is 1998 Compliant?Y <br /> UPCF(1/99 revised) <br /> l.a' <br />