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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION—FACILITY INFORM <br /> OPERATINGform per facility) <br /> 400. <br /> TYPE OF ACTION Fl1.NEW PERMIT (15.CHANGE OF INFORMATION ® 7.PERMANENT FACILITY CLOSURE <br /> (Check one item only) ❑ 3_RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION PROS3snn <br /> TOTAL NUMBER OF USTs AT FACILITY 406- FACILITY ID k — -- <br /> 1 (A err Use Onl 3, <br /> BUSINESS NAME(Same.FACILITYNAMEor DBA-Doing Busmn sAn <br /> Levand Famil Trust Pro a 03. CITY 0 <br /> BUSINESS SITE ADDRESS Trac <br /> 47 East Eleventh Street 605' <br /> °0'" Is the facility located on Indian Reservation or <br /> FACILITY TYPE ❑ I.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION Trust lands;9 ❑Yes ®No <br /> ❑ 3.FARM ❑ 4.PROCESSOR ® 6.OTHER <br /> IL PROPERTY OWNER INFORMATION 40e <br /> 4oT PHONE <br /> PROPERTY OWNER NAME (661)904-2133 <br /> Levand Family Trust 40 <br /> MAILING ADDRESS <br /> 24692 Sand Wed a Lane 4u. ZIP CODE 412 <br /> 41a. STATE <br /> CITY 91355 <br /> Valencia CA <br /> III. TANK OPERATOR INFORMATION 4282 <br /> 428-1, PHONE <br /> TANK OPERATOR NAME ( ) <br /> 8-3 <br /> Unknown <br /> MAILING ADDRESS <br /> 42s-0 STATE <br /> 428-5 ZIPCODE 42" <br /> CITY <br /> IV. TANK OWNER INFORMATION 41s <br /> 414. PHONE <br /> TANK OWNER NAME (661)1 904-2133 <br /> Levand Famil Trust °" <br /> MAILING ADDRESS <br /> 24692 Sand WedLe Laneo41s. ZIP CODE 419. <br /> n. STATE <br /> CITY CA 91355 <br /> Valencia 6.STATE AGENCY 420. <br /> OWNER TYPE: C] 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ <br /> ❑ 7.FEDERAL AGENCY ID &NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER 42 <br /> TY(TK)HQ 44- Call the State Board of Equalization,Fuel Tax Division,if there are questions. <br /> VI.PERMIT HOLDER INFORMATION 4 <br /> 13 <br /> 1.FACILITY OWNER ❑ 4.TANK OPERATOR <br /> Issue permit and send legal notifications and mailings to: 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 cern that the information provided herein is true,accurate,and in full Com fiance PHONEthl aI re uiremen[s. a25:• <br /> DATE <br /> 424 <br /> APPLIC T S1 A9/20/2013 (209)467-1006 <br /> 4n <br /> 42e. APPLICANT TITLE <br /> APP I ANT AME(Print) <br /> Agent for Levand Famil Trus[ <br /> Robert M <br /> UPCF UST-A Rev.(12/2007) <br /> 1 <br />