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FIED PROGRAM CONSOLIDATED FO , , ily G� <br /> TA KS <br /> UNDERGROUND STORAGE TANKS - FACILITY 10, <br /> (one page per 'te) Page <br /> OF ACTION ❑ 1.NEW SITE PERMIT ❑3.RENEWAL PERMIT 0&CHANGE OF INFORMATION ❑ TPERMANEN LO n E � � / <br /> .ck one item only) ❑4.AMENDED PERMIT specify change local use only ❑ 8.TANK REMOVED ►�1� <br /> ❑63EMPORARY SITE CLOSURE 400 <br /> I. FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 FACILITY ID# <br /> Califorina Fuel Supply �( � 1 <br /> 2575 Country Club, Stockton CA 95204 <br /> NEAREST CROSS STREET 401 FACILITY OWNER TYPE ❑4. LOCAL GENCY/DISTRICT* <br /> Plymouth ® 1.CORPORATION ❑5.COUNTY AGENCY* <br /> BUSINESS ® 1.GAS STATION [:13.FARM ❑5. COMMERCIAL ❑ 2. INDIVIDUAL ❑6.STATE AGENCY* <br /> TYPE ❑2. DISTRIBUTOR ❑4.PROCESSOR❑6. OTHER 403 ❑ 3.PARTNERSHIP ❑7.FEDERAL AGENCY* 402 <br /> TOTAL NUMBER OF TANKS Is facility on Indian Reservation or *If owner of UST is a public agency:name of supervisor of division,section or office <br /> REMAINING AT SITE trustlands? which operates the UST(This is the contact person for the tank records.) <br /> 3 404 ❑ Yes ® No 405 406 <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408 <br /> California Fuel Supply, Inc. 925-979-0242 <br /> MAILING OR STREET ADDRESS 409 <br /> 587 Ygnacio Valley Road <br /> CITY 410 STATE 411 ZIP CODE 412 <br /> Walnut Creek CA 94596 <br /> PROPERTY OWNER TYPE M 1. CORPORATION [:12. INDIVIDUAL ❑4. LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY <br /> ❑ 3. PARTNERSHIP [:15. COUNTY AGENCY ❑ 7.FEDERAL AGENCY 413 <br /> III.TANK OWNER INFORMATION <br /> OWNER NAME 414 PHONE 415 <br /> ik.�fornia Fuel Supply, Inc. 925-979-0242 <br /> MAILING OR STREET ADDRESS 416 <br /> 587 Ygnacio Valley Road <br /> CITY 417 STATE 418 ZIP CODE 419 <br /> Carson CA 94596 <br /> TANK OWNER TYPE ® 1. CORPORATION ❑2. INDIVIDUAL ❑4. LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 420 <br /> ❑3. PARTNERSHIP [15. COUNTY AGENCY [17. FEDERAL AGENCY <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY TK HQ 44- 0 3 19 10 12 1 6 1 Call 916 322-9669 if questions arise 421 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE ❑ 1.SELF-INSURED ❑4.SURETY BOND [:17.STATE FUND ❑ 10. LOCAL GOVT MECHANISM <br /> METHOD(s) ❑2.GUARANTEE ❑5. LETTER OF CREDIT ❑8.STATE FUND&CFO LETTER ❑ 99.OTHER: <br /> ® 3. INSURANCE ❑6. EXEMPTION ❑9.STATE FUND&CD 422 <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 mailings will be sent to the tank owner unless box 1 or 2 is checked. ❑ 1.FACILITY ®2. PROPERTY OWNER ❑3.TANK OWNER 423 <br /> VII. APPLICANT SIGNATURE <br /> Certification-I certify that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNATURE O'F!A� PPLIC NT DATE 424 PHONE 425 <br /> t� 12/19/2006 925-979-0242 <br /> 14E OF APPLICANT(print) 426 TITLE OF APPLICANT 427 <br /> Ahmadi yV x Lv <br /> STATE UST FACILITY NUMBER(For local use only) 428 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 <br /> ORII <br /> r__...,, n <br />