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_. IFIED PROGRAM CONSOLIDATED FOUNDERGROUNDSTORAGETANK <br /> . . <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> TYPE OF ACTION ❑ 1.NEW PERMIT (One form per facility) <br /> (Check one item only) ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE <br /> ❑ 3.RENEWAL PERMIT 4°° <br /> ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY aoo. <br /> 3 FACILITY ID# <br /> (Agency Use Only) 4 3 4 <br /> BUSINESS NAME(xeme ss FgCILITY NAME or 3 1. <br /> Valero Corner Store #3698 3. <br /> "B Bus ssgs, <br /> BUSINESS SITE ADDRESS <br /> 153 E. 111h Street °' crry <br /> FACILITY TYPE ® 1.MOTOR VEHICLE FUELING aa3. Trac <br /> ❑ 3.FARM ❑ 2.FUEL DISTRIBUTION Is the facility located on Indian Reservation or 405. <br /> ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑Yes ®No <br /> PROPERTY OWNER NIL PROPERTY OWNER INFORMATION <br /> AME <br /> Valero California Retail Company 07, PHONE <br /> anx. <br /> MAILING ADDRESS (559) 582 0241 <br /> 685 W. Third Street 409. <br /> CITY <br /> Ala. ZIP CODE <br /> Hanford LATE °" 412. <br /> 93230 <br /> TANK OPERATOR NAME III. TANK OPERATOR INFORMATION <br /> Valero California Retail Com an 428-1. PHONE <br /> azx-z <br /> MAILING ADDRESS 559-582-0241 <br /> 685 W. Third Street 428-3 <br /> CITY <br /> axx-a STATE 42x- <br /> Hanford 5 ZIP CODE 428-6 <br /> CA 93230 <br /> TANK OWNER NAME IV. TANK OWNER INFORMATION <br /> Valero California Retail Company a'a PHONE <br /> 415. <br /> MAILING ADDRESS 559'582-0241 <br /> 685 W. Third Street ala. <br /> CITY <br /> Hanford a STATE ZIP CODE <br /> CA 419. <br /> OWNER TYPE: 93230 <br /> ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY az°. <br /> ❑ 7.FEDERAL AGENCY ® S.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 0 2 4 6 6 <br /> Call the Stale 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: <br /> ❑ 1.FACILITY OWNER ® 4.TANK OPERATOR 421 <br /> El3.TANK OWNER [15.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) ... <br /> ,= aoe. <br /> J <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I certif that the information rovided here <br /> APPLICANT SIGNATURE in icorn B <br /> true accura a and in full corn with legal re uirem y <br /> DATE aza. PHONE 425. <br /> APPLICANT NAME(print) az6 <br /> J" (559) 583-3298 <br /> Sand Huff APPLICANT TITLE an <br /> Com liance Coordinator <br /> UPCF UST-A Rev.(12/2007) <br />