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UNIFIED PROGRAINI CONSOLIDATED FORFI <br /> UNDERGROUNDSTORAGETANI< <br /> OPERATING PERMIT APPLICATION- FACILITY INFORMATION <br /> (Onc form per lucilil�i <br /> '1'YP1:01:ACTION ❑ I.NEW PI:RMIi' ❑ j r11:AAGI,Or I-F INIn r1o,C im <br /> F} 7 rl I MANI: T FAru.rrY CLOSURE <br /> !('Iru oue imm onl.'1 3.RENI: AI.PERMIT" ❑ , <br /> ❑ ❑ r7 'I'1141P0(L\R}'P,\C'lla'I'Y L'1.OtiURP: �.'I'R.ANSPI3K PERhII'I' <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBEROF I-STs AT IFAC'ILIT}' " <br /> ONE TACH i'hl 10 ii <br /> 1:t:avtr l;'sr(Jnll7 <br /> BUSINESS NA AIF IS-.,.::IV II-Tv s,xsn=.,,,DBA-chirp n,�,,,,:.::.,,, � <br /> Miles Trust Propeny <br /> BUSINISS SITE ADDRESS "" CITY 4 <br /> 1940 South,American Street.Stockton,CA 93207 <br /> FAC ILII'l"1'YPG I MO'r(JR VISI IICLP.Ftll'1.1 N(i ❑ a_ FI!IiL.DIS'rlttlll l'1'I(1N IS the t'acibly hxareJ on Indi:m Kezrnation nr <br /> ❑ 3.FN2M 4.PROCESSOR ❑ i,.O'II IER '1"rust lands" ❑Ves ❑No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPER I1 O\VNI'!R NAM I. v, PIIONIL .". <br /> Loy and Frances Miles Trust <br /> t 209 � j07-Sd'r? 6-14t2_ <br /> MAILING ADOR ESS nr, <br /> 6333 Pacific Avenue 4366 <br /> CITI' Stockton.CA 95207,713 SI'A 1"1: ZIPCODIi <br /> III. TANK OPERATOR INFORMATION <br /> 'IANICOPFRATORNAME III10NI"_ �-@ =" <br /> Lin, turd Frances Miles Trust 1 209 307•q,}7-7- 1 /L <br /> MAILING ADDRESS <br /> 6333 Pacific Aeenue.4366 <br /> Lillrs.., SIAll. iss ZIP CODI: c3.:, <br /> Stockton.CA 93207-3713 <br /> IV. TANK OWNER INFORMATION <br /> rANR O\\Nrq N'ANIr-, PIIONP: <br /> Lm•and Frances hliles'1'nu[ 209 )507-54.7--7 55 <br /> gz <br /> N7:AILIN'G ADDRESS a,• <br /> 6333 Pacific Avenue.4366 <br /> (I'll Stockton,CA 95207-3713 /•IPCODI( r.•, <br /> OWNER'I'Y11F' ❑ 4 LOCAL ACIENCYlO15rRIC'IN <br /> µµ❑��3.COUI'Y A(i13��N(.'1' ❑ P, l':\L11-1 A(}I[NCl' <br /> [17.FF.DERAI.,\CENCI' M% NON-GOVERNNIPk I <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUi4BER <br /> EY (IK) I1Q44- 1 1 ('all the Slow B" rdofFtlualizalion.Fuel'I'as Di%ismn,iidwreire yucstions. t'I <br /> VI. PERMIT HOLDER INFORMATION <br /> {ss :n <br /> uc pcnnitut send l<nal untilicalions mlJ mailina5 to'. ® 1,PAC'I1.1'1l'O\A'NEIt ® 4 1':WF OPIiRA'1'OR 23 <br /> EI 3.'I-ANK OV NPR 3.FACILFII'OPERA I'OR <br /> SUPI3RVISOR 01°DIVISION,SCC"I'ION.OR OFFICE(KaluircJ f'itr PUN ie,\ecncies 03111) ' <br /> VII.APPLICANT SIGNATURE <br /> CERTIF 'ATION: 1 eertir.N flint the inl'ornatiun trovided herein is[rue,accurate and in Cull com 3lianee tvilh Iernl re[uiremen Lc. <br /> APP. rSICiN D,"1 ±+ PI IONS �•'. <br /> AW I7 1 <br /> :\P JC N 'NAM-(print) a+-<. A PLICAN"r"1*1 I'LE 2±7 <br /> Reba Veltri Truslre <br /> UPCF UST-A Rev.(12/2007) R E C N E <br /> JUN 0 7 2017 <br />