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IED PROGRAM CONSOLIDATED FO <br /> r UNDERGROUNDSTORAGETANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION ❑ I.NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENTLY CLOSED SITE 400 <br /> (Check one item only) <br /> ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY SITE CLOSURE ❑ 9.TRANSFER PERMIT <br /> I.FACILITY/SITE INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404 I FACILITY ID4 <br /> 13 FA0005704 <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 <br /> SHINKO ELECTRIC AMERICA INC <br /> BUSINESS SITE ADDRESS un CITY 104 <br /> 551 CARNEGIE ST MANTECA <br /> FACILITY TYPE ❑X 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403 1,facility or Indian Reservation or 405 <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER trusdands? ❑ yes ❑x No <br /> II.PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 40� PHONE 408 <br /> UNKNOWN <br /> MAILING ADDRESS <br /> 409 <br /> CITY 410 STATE 411 ZIP CODE 412 <br /> IIL TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 4za-1 PHONE 429-2 <br /> MAILING ADDRESS 428-3 <br /> CITY 4284 STATE 428-5 ZIP CODE 42M <br /> IV.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> UNKNOWN <br /> MAILING OR STREET ADDRESS <br /> 416 <br /> CITY 417 STATE 418 ZIP CODE <br /> 419 <br /> TANK OWNER TYPE ❑ 4,LOCAL AGENCY/DISTRICT L 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420 <br /> ❑ 7.FEDERAL AGENCY ❑ S.NON-GOVERNMENT <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44 Call(916)322-9669 if questions arise 421 <br /> VI.PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: [ 1.FACILITY [14.TANK OPERATOR 423 <br /> ❑3.TANK OWNER 0 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION SECTION,OR OFFICE(Required for Public Agencies Only) <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION-I certify that the information provided herein is true and accurate to the beg <br /> APPLICANT SIGNATURE DATE 424 1 PHONE 425 <br /> APPLICANT NAME(print) 426 APPLICANT TITLE <br /> 427 <br /> UPCF UST-A <br />