BILLING 1994-2009 (2) - Laserfiche WebLink

Home Browse Search

• �IFIED PROGRAM CONSOLIDATED FORM* PR#:PR0231482 FAC#:FA0000720 UNDERGROUND STORAGE TANKS -FACILITCCC� f 8126 (YY�one page pe si TYPE OF ACTION ❑ I.NEW SITE PERMIT 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENTLY CLOSED SITE (Check one item only) 4.AMENDED PERMIT NOMMESSINAM ❑ 8.TANK REMOVED ❑6.TEMPORARY SITE CLOSURE 400 I.FACILITY/SITE INFORMATION 239 S STOCKTON ST,RIPON BUSINESS NAME(Sawn FACR.mNA mDBA-Doing Bumam As) 3 FACILITYID# I PR ID" MADSENS SUNRISE DAIRY FA0000720 PR0231482 NEAREST CROSS STREET FACILITY OWNER TYPE STOCKTON 401 ❑ 1.CORPORATION El 4.LOCAL AGENCY/DISTRICT- ry El S.COUNTY AGENCY" BUSINESS 1'GAS STATION ❑3.FARM ❑ 5.COMMERCIAL ��'INDIVIDUAL El 6.STATE AGENCY" TYPE W ❑ 2.DISTRIBUTOR ❑ 4.PROCESSOR ❑ 6.OTHER 403 ❑ 3.PARTNERSHIP ❑ 7.FEDERAL AGENCY" 402 TOTAL NUMBER OF TANKS Is facility on Indian Reservation or 9fownerofUST is a public agency:name ofsupervisor ofdivision,section or office which operates REMAINING AT SITE trustlands? the UST(This is the context person for the tank records.) p 4M ❑ Yes ® No 405 ` ,..R OBE14 T. 406 R.PROPERTY OWNER INFORMATION PROPERTY OWNER NAME a01 PHONE mom, E Ra rn,a16C-A a�4 .5 3N�� MAHJNG OR STREET ADDRESS 409 239 S STOCKTON CITY 410 STATE411 ZIP CODE 412 RIPON CA 95366 PROPERTY OWNER TYPE .CORPORATION K2.INDIVIDUAL ❑ 4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY [:13.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY 413 III.TANK OWNER INFORMATION TANK OWNER NAME 414 PHONE 415 MADSEN ROBERT&CAROL MAILING OR STREET ADDRESS 239 S STOCKTON d16 CITY 417 1 STATE 418 ZIP CODE 019 RIPON CA 95366 TANK OWNER TYPE ffl 1.CORPORATION 1%2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY 420 ❑ 3.PARTNERSHIP 115.COUNTY AGENCY ❑ 7.FEDERAL AGENCY IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY(TK)HQ 44- 44-020313 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 MECHANISM ❑2.CUARANfEE 1:15.LETTER OF CREDIT 8.STATE FUND&CFO LETTER ©99.OTHER ❑3.INSURANCE ❑6.EXEMPTION ❑ 9.STATE FUND&CD 422 VI.LEGAL NOTIFICATION AND MAILING ADDRESS Check one box to indicate which address should be used for legal notificafiens and mailing. ® L FACILITY ❑2.PROPERTY OWNER ❑3.TANK OWNER 423 Legal cations and mailing will be sent to the tank owner unless box 1 or 2 is checked. VII.APPLICANT SIGNATURE ni lion-I certify that the information provided herein is me and accurate to the best ofmy knowledge. Si TOUCANT DATE 424 PHON 425 s•� Z-o3 pant) 426 TITLE OF APPLICANT 4n . STATE UST FACILITY NUMBER(For local ue ony) 428 1998 UPGRADE CERTIFICATE NUMBER(For kxal use arty) 429 Is 1998 Compliant?Y UPCF(1/99 revised)