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IFIED PROGRAM CONSOLIDATED FORM40 PR#:PRO234383 FAC#:FA0003670 UNDERGROUND STORAGE TANKS - FACILITY 6K3 (one page per site) /�S,�' TYPE OF ACTION ❑ L NEW SITE PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑7.PERMANENTLY CLOSED SITE (Check one item only) ❑4.AMENDED PERMIT spcdychospeknd u4e only _ ❑ 8.TANK REMOVED ❑6.TEMPORARY SITE CLOSURE I.FACILITY/SITE INFORMATION 14175 E HWY 26,LINDEN BUSINESS NANtE isame as FACILITY NAME.DBA-Doing Bairns Aa) 3 FACILITY ID# PR NiI I LINDEN ASSOCIATED GROWERS FA0003670 PR0234383 NEAREST CROSS STREET sol FACILITY OWNER TYPE [14.LOCAL AGENCY/DISTRICT- HWY 26 ® I.CORPORATION ❑ 5,COUNTY AGENCY' BUSINESS ❑ I.GAS STATION ❑3.FARM ❑ 5.COMMERCIAL ❑ 2.INDIVIDUAL ❑6.STATE AGENCY' TYPE ❑ 2.DISTRIBUTOR ❑4.PROCESSOR ❑ 6.OTHER 40l ❑3.PARTNERSHIP ❑ 7.FEDERAL AGENCY' TOTAL NUMBER OF TANKS Is facility on Indian Reservation or 9f owner of UST is a public agency:name of supervisor ofdiviuon,section or once which operates REMAINING AT SITE tmtlands? the UST(Thin is the contact person for the tank records.) 4oa ❑ Yes ® No 405 LAWRENCE J CELLE 406 11.PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407NE PHOa0s 209)931-4800 MAILING OR STREET ADDRESS 409 Same AS Site CITY 410 1 STATE 411 ZIP CODE ala Same As Site Same As Site Same As Site PROPERTY OWNER TYPE ❑ 1,CORPORATION ® 2.INDIVIDUAL ❑ 4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY ❑3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY 413 ID.TANK OWNER INFORMATION TANK OWNER NAME 414 PHONE 415 LAWRENCE J CELLE 209 9314800 MATING OR STREET ADDRESS 416 CITY 14175 E HWY 26 an 1 STATE 418 ZIPCODE 419 Same As Site Same As Site Same As Site TANKOWNERTYPE ❑ I.CORPORATION ❑X 2.INDIVIDUAL ❑ 4.LOCAL AGENCY/DISTRICT ❑ 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- Call(916)322-9669 if questions arise 421 V.PETROLEUM UST FINANCIAL RESPONSIBILITY INDICATE METHDD(s) ❑ 1.SELF-INSURED ❑4.SURETY BOND ❑ 7.STATE FUND ❑ HL LOCAL GOVT MECHANISM ❑2.GUARANTEE ❑5.LETTER OF CREDIT ❑ S.STATE FUND&CFO LETTER X❑99.OTHER ❑3.INSURANCE 1:16.EXEMPTION ❑ 9.STATE FUND&CD 422 VL LEGAL NOTIFICATION AND MAILING ADDRESS Check one box to indicate which address should be used for legal notifications and mailing. ® 1,FACILITY ❑2.PROPERTY OWNER ❑3.TANK OWNER 423 Legal notifications and mailing will be seat to the tack owner unless box I or 2 is checked. VII.APPLICANT SIGNATURE Certification-I certify that the information provided herein is true and accurate to the best of my knowledge. SIGNATURE OF APPLICANT DATE 424 1 PHONE 425 NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 427 STATE UST FACILITY NUMBER(Faloaluconly) 428 1998 UPGRADE CERTIFICATE NUMBER(Falodussonb) 429 Is 1998 Compliant?Y UPCF(1/99 revised)