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.bA IFIED Pitk 4.,RAM CONSOLIDATi D FORM PRO:PRO232573 EAC k:FA�/�0003941 UNDERGROUND STORAGE TANKS - FACILITY (one page per site) TYPE OF ACTION ❑ L NEW SITE PERMIT ❑ 3.RENEWAL PERMIT ❑ I CIIANGEOFINFOR\IVIO\ ❑ 7.PERMANENTLCLOSEDSIT (Check one item only) ❑ 4.AMENDED PERMIT spceifi chug,lac,use mdyS � 8.TANKREMOVED m a A`t i'i"U'a'§ n. IIPOK,ARt SIIECLOSURE 40a I.FACILITY/SITE INFORMATION 2650 MACARTHUR DR,TRACY BUSINESS NAME(Semeas FACIUTYNAMEm DBA-Doing Busiwsa As) y FACILITY B)# PR ID# ORCHARD SUPPLY HARDWARE#1570 FA 1941 PR0232573 NEAREST CROSS STREET FACILITY OWNER TYPE ❑ 4.LOCAL AGENCY/DISTRICT* MACARTHUR J01 M 1.CORPORATION ❑ 5.COUNTY AGENCY' BUSINESS ❑ I.GAS STATION E] 3.FARM E] 5.COMMERCIAL ❑ 2.INDIVIDUAL El6.STATE AGENCY* TYPE El 3.PARTNERSHIP 402 ❑ 2.DISTRIBUTOR E] 4.PROCESSOR ❑ 6.OTHER 403 ❑ 7.FEDERAL AGENCY' TOTAL NUMBER OF TANKS Is facility on Indian Reservation or *Ifowner ofUST is a public agency name ofsupervismof,ivision,section or office which operates REMAINING AT SITEtrustlands? the UST(This is the contact person for the tank records.) 4e4 ❑ Yes ®No 405 ORCHARD SUPPLY HARDWARE 406 II.PROPERTY OWNER INFORMATION PROPERTY OWNERNAME 407 PHONE 468 ORCHARD SUPPLY HARDWARE CORP 408 281-3500 MAILING OR STREET ADDRESS 409 PO BOX 49024 CITY 410 STATE 411 ZIP CODE 412 SAN JOSE CA 95161-9024 PROPERTY OWNER TYPE N1 1,CORPORATION ❑ 2.INDIVIDUAL ❑ 4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY ❑3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY 413 Ill.TANK OWNER INFORMATION TANK OWNER NAME ala PHONE 415 ORCHARD SUPPLY HARDWARE CORP 408 281-3500 MAILING OR STREET ADDRESS 416 PO BOX 49024 CITY 417 STATE g ZIP CODE ale SAN JOSE CA 95161-9024 TANK OWNER TYPE Q 1,CORPORATION ❑ 2.INDIVIDUAL 1:14.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- 44-034322 Call(916)322-9669 if questions arise 021 V.PETROLEUM UST FINANCIAL RESPONSIBILITY INDICATE METHOD(s) ❑ 1 SELF-INSURED ❑4.SURETY BOND ❑ 7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM ❑2.GUARANTEE ❑ 5.LETTER OF CREDIT ❑ 8.STATE FUND&CFO LETTER 19199.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 mailing. ® 1,FACILITY ❑ 2.PROPERTY OWNER El 3.TANK OWNER 423 Legal notifications and mailing will be sent to the tank owner unless box I or 2 is checked. VII.APPLICANT SIGNATURE Certification-1 certify that the information provided herein is true and accurate to the best of in,knowledge. SIGNATURE OF APPLICANT DATE azo PHONE 425 NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 427 STATE UST FACILITY NUMBER(For low a•ams) 428 1998 UPGRADE CERTIFICATE NUMBER(For low ase omy) 029 Is 1998 Compliant?Y UPCF(1/99 revised)