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1 Dec 12 08 03:45p John Johnson _ 916-443-6225 p.2 <br /> N� r <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUNDSTORAGETANK <br /> OPERATING PERNIIT APPLICATION—FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION X1.NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANEMFACILITY CLOSURF. �a <br /> (Check me kern only) ❑ 3.RENEWALPERMR ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> L FACILITY INFORMATION ! 9T/ 471. <br /> TOTAL NUMBER OF USTs AT FACILITY ' FACa 1.1 <br /> BUSINESS NAME( <br /> wFACO1TYwA m -D4h.nin.eaA,) 3. <br /> BUSINESS Sf1EADDRESS sat CITY �a <br /> 135/0 <br /> FACI.I7Y TYPE �1.MOTOR LE FUELING ❑ 2.FUEL DISTRIBUTION +03' Is the facility bcan dom ltsdi Reser,aden um +05' <br /> 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Tsun lands' ❑Yo No <br /> H PROPERTYOWNERINFORMATION <br /> PROPERTY OWNER NAME � / �� PHONE 4os. <br /> OR Ace, AW2W eas� / /pdGrC� LLC 91 7/2.3 NZ <br /> MAILING ADDRESS <br /> A� 9W <br /> C1TY 41(1 STATE 411. ZIP CODE ux. <br /> �a m�4 r. 94GZ3 <br /> M. TAW OPERATOR INFORMATION <br /> TANK OPERATOR NAME / PHONE sxax <br /> BP mac» /.tt�vd� �o'asf Priblalm a26L L' (916 ) K/,p -3 9q 2- <br /> MAILING ADDRESS <br /> 4x83 <br /> CITY <br /> STATE *las ZIPCODE <br /> +nc <br /> Za PzZAxa �a?. 90623 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER Nn xa PHONE ns. <br /> 3. /{eco sz �'oasz� i-oc>/kcZa-' 2Z 4:71 (916 ) W2-3 <br /> MAILIJG ADD SS +Is <br /> tr ei7 � �, <br /> Cf1Y nn STATE 438 ZIPCODE 419. <br /> �, �z�a 90623 <br /> OWNER TYPE. ❑ 4.LOCAL AGENCYIDISTRICT ❑ 5.COUNIYAGENCY <br /> ❑ 6.STATE AGENCY +m <br /> ❑ 7.FEDERAL AGENCY <br /> ❑ B.TON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TY-)HQ 44" 1 1 1 1 1 1Call the Sate Board ofEglmliulian,Fud Tax Division,iC there ate questions. 4r <br /> VL PERMIT HOLDER INFORMATION <br /> Issue Penmt and send legal nttifiwtioms and v whir s b: L FACILITY OWNER ❑ 4.TANK OPERATOR 4z3 <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION.OR OFFICE(Required Far Public Agencies Only) +cc. <br /> VI.APPLICANT SIGNATURE <br /> CERTIFICATION: t certify that tle hdn,,nad.n ruvided herein is true,ftcm" and in IRB cam Haace wits le 0 requimm ts. <br /> APPLIC IGN DATE 424. PHONE ass. <br /> APPLICANT NAME /z'12.08 9/G e1 3-6 Z <br /> (print) ass APPLICANT T/TLE <br /> UPCF UST•A Rev.(12R0a7) <br />