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t,.w- <br /> RE mI �ED <br /> UNIFIED PROGRAM CONSOLIDATED FORM APR 11 2017 1' lI//I <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION ?K 051H 93 <br /> 8� IP <br /> TYPE'.OF ACTION ❑ I.NEW PERMIT ❑ 5.C'HANGP OF INFORMATION U 7. PERMANENT FADEMOA NT 4W <br /> (Check one iwm o.EO ❑ 3.RENEWAL PERMIT ❑ 6 TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> T'O'TAL NUMBER OF USTs AT FACILITY 404 <br /> ONE FACILITY ID# 1. <br /> (AgenqUse Only) <br /> BUSINESS NAME IS.,—FAOI try NANIE,,,DBA-Dolat,B.. ...as , <br /> Miles Trust Property <br /> BUSINESS SITE ADDRESS CITY 104 <br /> 1940 South American Street,Stockton.CA 95207 <br /> FACILITY l'YPE I MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRI131.11,)P: � Is the facilav located an Indian Rescrvution or J05' <br /> ❑ 3.FARM ❑ 4_PROCESSOR ❑ 6.6TH ER Trust lands' ❑Yes ❑No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPFRIYOWNER NAME "' PHONE 4118 <br /> Loy and Frances Miles Trust 209 507- <br /> MAILING ADDRESS 401 <br /> 6333 Pacific Avenue,9366 <br /> CITY Stockton.CA95207-3713 410 SEE:ATI 41i ZIP CODE m <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERA FORNAME PHONE <br /> Loy and Frances Miles Trust � 209 �507-54TF �rl <br /> MAILING ADDRESS l� 418-11 <br /> 6333 Pacific Avenue,#366 <br /> CITY Stockton,CA 95207-3713 4Y 4 STATE 42s-' ZIPCODP 428-6 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME n4 PHONE 41? <br /> Lov and Frances Miles Trust ( 209 507-5473 5'-"Z <br /> MAILING ADDRESS 416 <br /> 6333 Pacific Avenue,9366 <br /> CITY Stockton.CA 9507-3713 411 STA'T'E 'is. ZIP CODE 4w <br /> OWNER TYPE. ❑ 4. LOCAI.AGENCY/DISTRICT ❑�5_COUNTY AGENCY ❑ 6.STAII'A61.NCY 410 <br /> El 7. 1'I[DPRAI..AGENCY W <br /> q�{(3. NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY (TK) HQ 44- 1 1 Call the Smte HOurd a f I'_qualiiauon.Fucl Tas Division,dthere are questions. 4'1 <br /> VI. PERMIT HOLDER INFORMATION <br /> Issue Penni[and send(coal notilicaions and mailings to' ® I. FAC'11_ITYOWNER 4, <br /> - �] 3.LANK OPl[RATOR <br /> ❑ 3.TANK OWNER © 5. FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required Por Public Agencies Onl} 061 - <br /> VIL APPLICANT SIGNATURE <br /> CERTI A'FION: I certify that the information provided herein is true,accurate,and in full compliance with legal requirements. <br /> ASIMGN DATE <br /> PP <br /> APMCPT NAM (print) 4z6. APPLICANT TITLE 427 <br /> Reba Veltri Trustee <br /> UPCF UST-.A Rev.(12/2007) <br />