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r I e <br /> tWa IED PROGRAM CONSOLIDATED FO <br /> TANKS oi <br /> UNDERGROUND STORAGE TANKS - FACILITY b <br /> (One page per site) Page_1_of 7 <br /> TYPE OF ACTION ®1.NEW PERMIT ❑3.RENEWAL PERMIT [15.CHANGE OF INFORMATION ❑7.PERMANENTLY CLOSED SITE 400. <br /> (Check one item only) ❑4.AMENDED PERMIT (Specify change) ❑8.TANK REMOVED <br /> ❑6.TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3. FACILITY <br /> RALEY'S FUEL STATION#356 ID t <br /> NEAREST CROSS STREET J4 9S6E a PZ,41�14 k-k nn. FACILITY OWNER TYPE ❑4.LOCAL AGENCY/DISTRICT- 402_ <br /> FRONTAGE ROAD/HIGHWAY 99 ® 1.CORPORATION [15.COUNTY AGENCY' <br /> BUSINESS ® 1.GAS STATION ❑3.FARM ❑5.COMMERCIAL 403- ❑2.INDIVIDUAL [16.STATE AGENCY- <br /> TYPE ®2.DISTRIBUTOR [14.PROCESSOR ❑6.OTHER ❑3.PARTNERSHIP ❑7.FEDERAL AGENCY* <br /> TOTAL NUMBER OF TANKS 404- Is facility on Indian Reservation 495. "If owner of UST is a public agency: name of supervisor of division, section or 406. <br /> REMAINING AT SITE or trust lands? office which operates the UST. (This is the contact person for the tank records.) <br /> N/A ❑Yes ®No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 607 PHONE 408. <br /> LA MORADA PARTNERSHIP,LTD. (916)373-6410 <br /> MAILING OR STREET ADDRESS 409. <br /> 500 WEST CAPITOL AVENUE <br /> CITY 410, STATE 411. ZIP CODE 412. <br /> SACRAMENTO CA 95605 <br /> PROPERTY OWNER TYPE ❑ 1.CORPORATION Lj 2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 413. <br /> ®3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> III. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414, PHONE 415. <br /> RALEY'S (916)373-3333 <br /> MAILING OR STREET ADDRESS 416. <br /> 500 W. CAPITOL AVENUE <br /> CITY 417 STATE 41s. ZIP CODE 419. <br /> WEST SACRAMENTO CA 95605 <br /> TANK OWNER TYPE ® 1.CORPORATION ❑2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 420. <br /> [13.PARTNERSHIP ❑5.COUNTY AGENCY [17.FEDERAL AGENCY <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY TK HQ 44- 1 0 1 3 1 1 1 8 1 4 1 9 1 Call 916 322-9669 if questions arise 42L <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) M 1.SELF-INSURED ❑4.SURETY BOND [17.STATE FUND [110.LOCAL GOVT MECHANISM 622 <br /> [12.GUARANTEE [15.LETTER OF CREDIT [IS.STATE FUND&CFO LETTER ❑99.OTHER: <br /> [13.INSURANCE ❑6.EXEMPTION ❑9.STATE FUND&CD <br /> VI. LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one box to indicate which address should be used for legal notifications and mailing. <br /> Legal notifications and[tailings will be sent to the tank owner unless box I or 2 is checked. ❑ L FACILITY [12. PROPERTY OWNER ®3.TANK OWNER 423. <br /> VII. APPLICANT SIGNATURE <br /> Certification: 'fy that the info n provided herein is true and accurate to the best ofmy knowledge. <br /> S OF PLIC DATE 424, PHONE 425. <br /> /a Tj Oro (805)546-2050 <br /> NO ICANT int) 426_ TITLE APPLICANT 427 <br /> L E c/o eda-design professionals PROJECT MANAGER <br /> STATE UST FACILITY NUMBER(Agency me only) 428. 1998 UPGRADE CERTIFICATE NUMBER(Agency use only) 429_ <br /> (See Data Element 1,above. <br /> UPCF Hwfwrc-a(1/99)-1/2 http://www.unidocs.org Rev.02/16/00 <br />