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IFIED PROGRAM CONSOLIDATED FORM ,Y3 3 PR#:PR0232348 J FAC#:FA0003944 UNDERGROUND STORAGE TANKS - FACIL (one page per site) TYPE OF ACTION ❑ I.NEW SITE PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENTLY CLOSED SITE (Check one itemonly) ❑ 4.AMENDED PERMIT ❑ 8.TANK REMOVED ❑6.TEMPORARYSITE CLOSURE 400 I.FACILITY/SITE INFORMATION 11180 S VALLEJO CT,FRENCH CAMP BUSINESS NAME(samcaa FACILITY NAME or DBA-Doing Business M) s FACILITY ID# PR iD# ROBINSON TRUCKING FA0003944 PRO232348 1 NEAREST CROSS STREET FACILITY OWNER TYPE E] 4,LOCAL AGENCY/DISTRICT- VALLEJO enI ❑ I.CORPORATION ❑ 5.COUNTY AGENCY" BUSINESS ® I.GAS STATION ❑ 3.FARM ❑ 5.COMMERCIAL ❑2.INDIVIDUAL ❑ 6.STATE AGENCY* TYPE E] 2. E] El 3.PARTNERSHIP 402 2.DISTRIBUTOR 4.PROCESSOR 6.OTHER 403 ❑ ].FEDERAL AGENCY* TOTAL NUMBER OF TANKS I5 facility on Indian Reservation or *Ifowner of UST is a public agency:name of supervisor ofdivision,mcdcn or office which operates REMAINING AT SITE trustlands? the UST(This is the contact person for the lank records.) 400 ❑ Yes ® No 405 JIM ROBINSON 406 II.PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407 PHONE 405 ROBINSON JIM REX 209 982-5423 MARSNG OR STREET ADDRESS 4a9 2533 E LOVELACE CITY Oto STATE 411 ZIP CODE 432 MANTECA CA 95336 PROPERTY OWNER TYPE ❑ L CORPORATION ® 2.INDIVIDUAL ❑ 4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY E13.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY 40 I11.TANK OWNER INFORMATION TANKOWNERNAME 414 PHONE 415 ROBINSON TRUCKING 209 982-5423 MAILING OR STREET ADDRESS 416 11180 S VALLEJO CT CITY 47 STATE 4I9 ZIP CODE 4I9 Same As Site Same As Site Same As Site TANK OWNER TYPE ❑X I.CORPORATION El 2.INDIVIDUAL El 4.LOCAL AGENCY/DISTRICT L1 6.STATE AGENCY 420 ❑3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY(TK)HQ 44- 44-025008 1 Call(916)322-9669 if questions arise 421 V.PETROLEUM UST FINANCIAL RESPONSIBILITY INDICATE METHOD(s) ❑ 1.SELF-INSURED ❑4.SURETY BOND ❑ 7.STATE FIND ❑ 10.LOCAL GOVT MECHANISM 112.GUARANTEE ❑5.LETTER OF CREDIT ❑ 8.STATE FUND&CFO LETTERX❑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 notifications and ousting. ® L FAC111TY ❑2.PROPERTY OWNER ❑3.TANK OWNER 423 Legal notifications and mailing will be sent to the tank owner unless box I or 2 is checked. VH.APPLICANT SIGNATURE Certification-I comfy that the information provided herein is me and accurate to the best army knowledge. SIGNATURE OF APPLICANT DATE 424 PHONE 4i5 NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 427 STATE UST FACILITY NUMBER(Foloral ne muy) 428 1998 UPGRADE CERTIFICATE NUMBER(For ural use may) 429 Is 1998 Compliant?Y UPCF(1/99 revised)