Laserfiche WebLink
A <br /> 11,4101" I�I( <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION—FACILITY INFORMATION <br /> (One fottn per facility) <br /> TYPE OF ACTION ❑ 1.NEW PERMIT ® 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 4aa <br /> /t'Ixa'k rum irern mr/5y ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTALNIIMBFR OF USTS AT FACILITY ' WA—led G' <br /> FACILITY IDO <br /> (Agency Use Only) <br /> BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3 <br /> GI Trucking dba Estes West <br /> BUSINESS SITE ADDRESS 101- CITY 1M. <br /> 7611 S. Airport Way Stockton <br /> FACILITY TYPE ❑ I.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403_ is the facility hated on Indian Reservation or <br /> ❑ 3.FARM ❑ 4.PROCESSOR 0 6.OTHER Trust lands? ❑ I.Yes ® 2.No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE we_ <br /> Estes Terminals of California LLC 804 353-1900 <br /> MAILING ADDRESS 409- <br /> PO Box 25612 <br /> CITY Oto STATE 411. ZIPCODE 413- <br /> Richmond I VA 23260 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 421-1. PHONE 429-2, <br /> Estes West (209) 982-1841 <br /> MAILING ADDRESS ZT3 <br /> 7611 S. Airport Way <br /> CITY +2€A. STATE 428-5 ZIP CODE 42" <br /> Stockton CA 95206 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 41+ 1 PHONE 415. <br /> Estes Terminals of California LLC (804) 353-1900 <br /> MAILING ADDRESS 416' <br /> PO Box 25612 <br /> CITY 417 1 STA"fE 412 ZIP CODE 419. <br /> Richmond VA 23260 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCYIDISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 4$0 <br /> ❑ 7.FEDERAL AGENCY ® 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- O O 7 141 1 1 O 1 Call the State Board of Equalization,Fuel Tax Division-if there are questions. 421 <br /> VI.PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: ❑ L FACILITY OWNER ❑ 4.TANK OPERATOR 433 <br /> Z 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Regwred for Public Agencies Only) 406 <br /> VII. APPLICANT SIGNATURE <br /> CERTIFICATION: 1 certif t e i*Ormalijur1rovided herein is true accurate and in full cinatilliance with legal re uirements <br /> APPLICANT SIGNATURE DATE i24 1 PHONE J15 <br /> APPLICANT N .(print 426 APPLIC NT ITLE "' <br /> � <br /> N'- <br /> I1PC.FUST-A Rev.112/2007)-1/2 w .unidocs.org ,'n / <br />