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RECENED <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK MAY 3 12017 <br /> OPERATING PERMIT APPLICATION—FACILITY INFORMATION <br /> °` re H <br /> TYPE.OF ACTION Ltj I.NEW PERMIT ❑ S.CHANGE OF INFORMATION ❑ 7.PERMANENT FACIIbTffT .m Gam' <br /> (Check one item only) ❑ ; RENEWAL PERMIT ❑ 6.TEMPORARY FACILI'['Y CLOSURE ❑ 9.TRANSFER PERMIT T <br /> I. FACILITY INFORMATION p 051 PAD 54 437 <br /> TOTAL NUMBER OF USTs AT FACILITY 44' 1 FACILITY ID a <br /> 3 (Agenq Use Only) <br /> BUSINESS NAME(same u 1-ACusn'NME.DBA-W.sHao ..As) 3. <br /> ARCO AM/PM Manteca <br /> BUSINESS SITE ADDRESS 163. CITY 104, <br /> 1904 Daniels Street Manteca <br /> FACILITY TYPE ® L MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 203' Is the facility located on Indian Reservation or 40' <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑Yes ®No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME evr, PHONE 428 <br /> Manteca Petroleum, Inc. -Ranjeet Singh 209 579-4014 <br /> MAILING ADDRESS 409 <br /> 3115 Cynthia Court <br /> CRY 410. 1 STATE 411, ZIP CODE 412. <br /> Tracy CA 95377 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. 1 PHONE 42&3 <br /> Same as Property Owner ( ) <br /> MAILING ADDRESS - 428-3 <br /> CITY 4zs4 STATE 42-&3 ZIP CODE 428.6 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414, PHONE 415. <br /> Same as Property Owner ( ) <br /> MAILING ADDRESS 416, <br /> CITY 417. 1 STATE 419. ZIP CODE 419, <br /> OWNER TYPE: ❑ 4.LOCAL AGENCYIDISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 130 <br /> ❑ 7.FEDEPAL AGENCY IM 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 1 1 1 TBD Call the State Board of Equalization,Fuel Tax Division,if there arc questions. 421' <br /> VI.PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: 4D <br /> I.FACILITY OWNER ❑ 4.TANK OPERATOR <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> 406. <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that the informadon provided herein is true,accurate,and in full tout fiance with legal requirements. <br /> ANT DATE azo. PHONE dz5, <br /> C 5 i' fi—! 7 209 579A#4 <br /> LIC AME lint) 426. APPLICANTTfILE m <br /> Ranjeet Singh Owner <br /> UPCF UST-A Rev.(122007) <br />