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JPWIED PROGRAM CONSOLIDATED F4W �;, 0-1- TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page per site) Page_of <br /> TYPE OF ACTION ❑ 1.NEW SITE PERMIT ❑3.RENEWAL PERMIT 05.CHANGE OF INFORMATION ❑ 7.PERMANENTLY CLOSED SITE <br /> (Check one item only) ❑4.AMENDED PERMIT specify change local use only ❑ 8.TANK REMOVED <br /> ❑6.TEMPORARY SITE CLOSURE 400 <br /> I. FACILITY/ SITE INFORMATION <br /> BUSINESSNAME(SarreasFACILITYNAMEorDBA-DoingBusinessAs) 3 FACILITY ID# <br /> t <br /> Verizon California Incorporated-Manteca CO <br /> _N5AFXSTGROSS STREET 401 FACILITY OWNER TYPE ❑4.LOCAL AGENCY/DISTRICT* <br /> 430 Center Street ®1.CORPORATION ❑5.COUNTY AGENCY* <br /> BUSINESS ❑ 1.GAS STATION ❑3.FARM ❑5. COMMERCIAL ❑ 2.INDIVIDUAL ❑6.STATE AGENCY* <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR 06. 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 which <br /> REMAINING AT SITE trustlands? operates the UST(This is the contact person for the tank records.) <br /> One 404 ❑ Yes ®No 405 406 <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408 <br /> Verizon California Incorporated FKA GTE California Incorporated 800-331-8891 <br /> MAILING OR STREET ADDRESS 409 <br /> One Verizon Place <br /> CITY 410 1 STATE 411 ZIP CODE 412 <br /> Thousand Oaks CA 91362 <br /> PROPERTY OWNER TYPE O L CORPORATION ❑2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY 413 <br /> M. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> Verizon Services Group 800-331-8891 <br /> MAILING OR STREET ADDRESS 416 <br /> P.O.Box 725 <br /> CITY 417 1 STATE 418 ZIP CODE 419 <br /> Chino CA 91708 <br /> TANK OWNER TYPE ®1.CORPORATION ❑2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 420 <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 1 0 17 15 12 16 1 Call(916)322-9669 if questions arise 421 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s)®1.SELF-INSURED ❑4.SURETY BOND ❑7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM <br /> ❑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 /> SIGVFAPPLInCANT <br /> LIC DATE 424 PHONE 425 <br /> 5/29/01 909-613-1553 <br /> NAM (printj 426 TITLE OF APPLICANT 427 <br /> Masood H. Choudhury Environmental Consultant <br /> STATE UST FACILITY NUMBER(For local use only) 428 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 <br /> UPCF(1/99 revised) 8 Formerly SWRCB Form A <br />