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N IFIED PROGRAM CONSOLIDATED FO O PR #: PR0231470 utt FAC #: FA0003 11 g � STORAGE TANKS FACILITY UNDERGROUND - r (one page per site) TYPE OF ACTION ❑ I. NEW SUE PERMIT ❑ 3. RENEWAL PERMIT kd 5. CHANGE OF IIFORMATION ❑ 7. PERMANENTLY CLOSED SITE (Check one item only) ❑ 4. AMENDED PERMIT ❑ 8. TANK REMOVED ❑ 6. TEMPORARY SITE CLOSURE 40 I. FACILITY / SITE INFORMATION 816 E FRONTAGE RD. RIPON BUSINESS NAME (samrar FAca.nYN wDBA-Doing Rumam As) a FACILITY [D# PR ID# ^`rr FA0003911 11RO231470 NEAREST CROSS STREET yJ•I n._, e Q, (.L /-l.� 401 FAACCMITY OWNER TYPE ❑ 4. LOCAL AGENCY/DISTIUCTe �lJ~ T KI 1 . 2. INDIVIDUAL ❑ 6. STATE AGENCY - ].GAS TYPE ❑ 2. DISTRIBUTOR ❑ 4. PROCESSOR ❑ 6. OTHER 4m ❑ 3. PARTNERSHIP ❑ 7. FEDERAL AGENCY' 402 TOTAL NUMBER OF TANKS Is facility on Indian Reservation or gfowner of UST is a public agency: name of supervisor ofdivisiom section or office which operates REMAINING AT SITE trusdands? the UST (This is the contact person for the tank records) 404 ❑ Yes ® No 405 4% II. PROPERTY OWNER INFORMATION PROPERTY OWNER NAME' �� 4 V4I 407 PHONE TL:5 409 1 MAILING OR STREET ADDRESS 40 (L(✓ �� PRnX l I n77 () CITY4 OAI�o STATE 411 ZIP CODE 412 S3 �eexq-@N- CA 9sae1 PROPERTY OWNER TYPE =I. CORPORATION 92. INDIVIDUAL 04. LOCAL AGENCY/DISTRICT El 6. STATE AGENCY ❑ 3. PARTNERSHIP ❑ 5. COUNTY AGENCY ❑ 7. FEDERAL AGENCY 413 III. TANK OWNER INFORMATION TANK OWNER NAME 414 PHONE 415 VAN DE POL ENTERPRISES INC 209 465-3421 MAILING OR STREET ADDRESS 416 PO BOX 1107 CITY 4,7 STATE 419 ZIP CODE 419 STOCKTON I CA 95201 TANK OWNER TYPE ❑X I. CORPORATION ❑ 2. INDIVIDUAL ❑ 4. LOCAL AGENCY / DISTRICT 116. STATE AGENCY 420 ❑ 3. PARTNERSHIP ❑ 5. COUNTY AGENCY ❑ 7. FEDERAL AGENCY IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY (TK) HQ 44- 44-006773 1 Call (916) 322-9669 if questions arise 431 V. PETROLEUM UST FINANCIAL RESPONSIBILITY INDICATE METHOD(s) 111. SELF-INSURED 1:14. SURETY BOND X 7. STATE FUND ❑ 10. LOCAL GOVT MECHAMBM ❑ 2. GUARANTEE ❑ 5. LETTER OF CREDIT ❑ 8. STATE FUND&. CFO LETTER $99.OTHER ❑ 3. INSURANCE ❑ 6. EXEMPTION ❑ 9. STATE FUND & CD 422 VI. LEGAL NOTIFICATION AND MAILING ADDRESS �( Check one bon to indicate which address should be used for legal notifications and mailing. 41F1. FACILITY El 2. PROPERTY OWNER ¢L 3. TANK OWNER 423 Legal notifications and mailing will be sent to the tank owner unless box I or 2 is checked. VII. APPLICANT SIGNATURE Con ification -1 cemify, that the information provided herein is true and accurate to the best ofmy knowledge. SIGNATURE OF APPLICANT DATE 424 PHONE 425 NAME OF APPLICANT (print) 426 TITLE OF APPLICANT 427 77 rUSTFACILITYNUMBER(Fa,kxxtu,.iy) 429 1998 UPGRADE CERTIFICATE NUMBER(Formulouwly) 429 Is 1998 Compliant? Y UPCF (1/99 revised)