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01 ►�-31-0 -. <br /> 3FIED PROGRAM CONSOLIDATED FORABiN4�- <br /> PRM:PRO231OU <br /> FAC#:FA000404 <br /> UNDERGROUND STORAGE TANKS -FACILITY ltI( �b� <br /> (one page per site) <br /> TYPE OF ACTION ❑ L NEW SITE PERMIT ❑3.RENEWAL PERMIT 5.CHANGE OF INFORMATION <br /> (Check one item only) ❑ ❑ ].PERMANENTLY CLOSED SITE <br /> ❑ 4.AMENDED PERMIT ❑8.TANK REMOVED <br /> ❑6.TEMPORARY SITE CLOSURE 400 <br /> I.FACILITY/SITE INFORMATION 4051 NEWTON RD.STO KTON <br /> BUSINESS NAME(s,ou-a.FACRITYNu mDBA-Douglheba,.M) 3 FACILITY PR ID# <br /> PACIFIC BELL FA0004045 PR0231868 1 <br /> NEAREST CROSS STREET FACIWT'Y OWNER TYPE <br /> NEWTON 401 ❑ I.CORPORATION ❑4.LOCAL AGENCY/DISTRICT' <br /> BUSINESS ® 1.GAS STATION ❑ 2.INDIVIDUAL ❑5.COUNTY AGENCY- <br /> TYPE ❑3.FARM ❑ 5.COMMERCIAL ❑6.STATE AGENCY• <br /> ❑2.DISTRIBUTOR ❑4.PROCESSOR ❑ 6.OTHER 403 ❑3.PARTNERSHIP ❑ 7.FEDERAL AGENCY- 02 <br /> TOTAL NUMBER OF TANKS Is facility on Indian Reservation or <br /> REMAINING AT SITE tnutlands? alfownm cfUST is a public agency:name of supervisor ofdivision,sec0on or office which operates <br /> the UST(This is the contact person for the tank records.) <br /> 4.1❑ Yes ®No 05 PACIFIC BELL <a <br /> IL PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 4U9 <br /> PACIFIC BELL 510823-9824 <br /> MAILING OR STREET ADDRESS <br /> 2600 CAMINO RAMON RM 2EO50 409 <br /> CITY STATE <br /> 410 411 ZIP CODE adz <br /> SAN RAMON CA 1 94583 <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 /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME <br /> 4d4 PHONE as <br /> PACIFIC BELL 916 972-4086 <br /> MAILING OR STREET ADDRESS m+...0 / <br /> 2646 WAT A�. TA4 7]7 0 )6030 416 <br /> CITY 410 1 STATE 419 ZIP CODE 419 <br /> SACRAMENTO CA 95851 - foxg <br /> TANKOWNERTYPE ❑X 1.CORPORATION 02.INDIVIDUAL 04.LOCAL AGENCY/DISTRICT El 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- 44-031914 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 <br /> ❑2.GUARANTEE 1:15.LETTER OF CREDIT ❑ S.STATE FUND&CFO LETTER ®99.OTHER <br /> ❑3.INSURANCE ❑6.EXEMPTION ❑ 9.STATE FUND&CD 422 <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 4a <br /> Legal notifications and mailing will be sent o the lank owner unless box 1 or 2 is checked. <br /> VII.APPLICANT SIGNATURE <br /> Certification-1 certify that the information provided herein is true and accurate to the best ofmy knowledge. <br /> SIGNATURE OF APPLICANT DATE 424 PHONE an <br /> NAME OF APPLICANT(print) 424 TITLE OF APPLICANT 427 <br /> STATE UST FACILITY NUMBER(Fw l 1neowy) 428 1998 UPGRADE CERTIFICATE NUMBER votorlon,may) 429 <br /> Is 1998 Compliant?Y <br /> UPCF(1/99 revised) <br />