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) NT IFIED PROGRA&4�§pI,IDATED FORM PR#:PRO231 FAC#:FA0001909 RGROUM`STOiRAGE 3'�-FACH;1--m-------hT A .I., (one page per site) (Check Dere item ION ❑ L NEW SITE PERM" ❑3.RENEWAL PERMIT4.AMENDED PERMIT S.CHANGE OF INFORMATK>TI ❑ Q'7.�MANENTLY CLOSED SITE ❑ ❑S.TANK REMOVED ❑6.TEMPORARY SITE CLOSURE 400 I.FACILITY/SITE INFORMATION 1_856 W COUNTRY CLUB BLVD STnrICTON BUSINESS NAME(Same in FACKM NAME or DBA-Doug Bumps As) 3 FA ID# PR ID# COUNTRY CLUB FOOD&FUEL MINI MART FA0001909 PR02 D# ' NEAREST CROSS STREET FACILITY OWNER TYPE COUNTRY CLUB 401 ❑ 1.CORPORATION ❑4.LOCAL AGENCY/DISTRICT• BUSINESS ❑2.INDNIDUAL ❑5.COUNTY AGENCY+ TYPE ❑ 1.GAS STATION ❑3.FARM ❑S.COMMERCIAL ❑2.DISTRIBUTOR ❑4.PROCESSOR ❑6.OTHER 403 E]3. 6.STATE AGENCY+3.PARTNERSHIP �z TOTAL NUMBER F TANKS ❑7.FEDERAL AGENCY*Lc facility on Indian Reservation or Ifowner ofUST is a blit REMAAl1NG AT SITE trustlands? >n agency:name of supervisor of division,section or office which operates the UST(This is the contact person for the tank records.) eo4 Yes ®No 4os BAKHSIS$ 406 PROPERTY OWNER NAME 407 PHONE 409 oR ADDRESS 925 373-2565 409 CITY 410 STATE 411 ZIP CODE 412 CA 94551 O ® I.CORPORATION ❑ 2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY 413 III.TANK OWNER INFORMATION TANK OWNER NAME 41a PHONE 41s BAKHSIS SINGH-SUKHB KAUR 925 373-2565 MAILING OR STREET ADDRESS 1460 HEATHER LN 416 CITY 417STATE 419 ZIP CODE 419 LNERMORE CA 94551 TANK OWNER TYPE ❑ 1.CORPORATION ❑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- 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 FUND ❑ 10.LOCAL GOVT MECHANISM ❑2.GUARANTEE ❑5.LETTER OF CREDIT ❑ 8.STATE FUND&CFO LETTER M 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 mailing. ® 1.FACILITY ❑2.PROPERTY OWNER ❑3.TANK OWNER 423 Legal notifications and mailing will be sent to the tank owner unless box 1 or 2 is checked. VII.APPLICANT SIGNATURE CertiEcatias-I certify that the information provided herein is true and accurate to the best of my knowledge. SIGNATURE OF APPLICANT DATE 424 PHONE 425 NAME OF APPLICANT(print) az6 TITLE OF APPLICANT 427 STATE UST FACILITY NUMBER(For low no aoly) 428 1998 UPGRADE CERTIFICATE NUMBER(Fur focal use only) 429 Is 1998 Compliant?Y UPCF(1/99 revised)