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FIED PROGRAM CONSOLIDATED FOR11% r PR N:P 0231485 I I T^'I g FAC 0306 UNDERGROUND STORAGE TANKS -FA (2v1� ( �Q3 one page / per site) TYPE OF ACTION ❑ I.NEW SITE PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGEOFIN'FORMAHON ❑ ].PERMANENTLY CLOS (Check one item only) ❑4,AMENDED PERMIT mirychm,c iaral,�cony ❑ B.TANK REMOVED ❑6.TEMPORARY SITE CLOSURE 400 1.FACILITY/SITE INFORMATION 1405 CALIFORNIA ST,ESCALON BUSINESS NAME(samcas FACILITY NAME orOBA-Doing Bmmas As) FACILITY IDN PA IDN EMIL'S LI UOR&SPORTS SHOP* FA0000306 PRO231485 NEAREST CROSS STREETFACILITY OWNER TYPE CALIFORNIA 461 El 1.CORPORATION El 4.LOCAL /DISTRICT' BUSINESS 1.GAS STATION ❑ 2.INDIVIDUAL [:15.COUNTYY AAGENCGENCY' TYPE ® ❑ 3.FARM ❑ 5.COMMERCIAL 6.STATE AGENCY' ❑ 2.DISTRIBUTOR El4.PROCESSOR ❑ 6.OTHER 401 ❑ ;'PARTNERSHIP ❑ ].FEDERAL AGENCY' TOTAL NUMBER OF TANKS Is facility on Indian Reservation or *Ifowner of UST is a public agency:name of supervisor ofdivision,section or office which operates REMAINING AT SITE trustlands? the UST(This is the contact person for the tank records.) ❑ Yes M No 411 406 11.PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407PHONE 408 ROBERT LEASE 209 838-7674 MAILING OR STREET ADDRESS 409 2307 YOSEMITE AVE CITY 010 1 STATE 411 Zip CODE 412 ESCALON CA 95320 PROPERTY OWNER TYPE ® 1.CORPORATION ❑ 2.INDIVIDUAL 1:14.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY ❑3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY 413 III.TANK OWNER INFORMATION TANK OWNER NAME 414 PHONE 415 ROBERT LEASE 209 838-7674 MAILING OR STREET ADDRESS 2307 YOSEMITE AVE ale CITY 417 STATE 418 ZIPCODE 419 ESCALON I CA 95320 TANK OWNER TYPE 1.CORPORATION ❑ 2.INDIVIDUAL ❑4.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- Call(916)322-9669 if questions arise 421 V.PETROLEUM UST FINANCIAL RESPONSIBILITY INDICATE METHOD(s) ❑ 1.SELF-INSURED 1:14.SURETY BOND ❑ 7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM ❑2.GUARANTEE ❑5.LETTER OF CREDIT ❑ 8.STATE FUND&CFO LETTER 19 99.OTHER 113.INSURANCE 1:16.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. IN 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 Certification-I certify that the information provided herein is hue and accurate to the best of my knowledge. SIGNATURE OF APPLICANT DATE 424 PHONE 425 NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 427 STATE UST FACILITY NUMBER(Forlool aconly) 428 1998 UPGRADE CERTIFICATE NUM13ER(Forlooduseany) 429 Is 1998 Compliant?Y UPCF(1/99 revised)