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ED PROGRAM CONSOLIDATED FO <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION KI NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400' <br /> (Cheek one item only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> L FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 40/- FACILITY ID 4 _ <br /> 3 (Agency Use Only) <br /> BUSINESS NAME(Samem FAMW NA .DBA-Doing Budnma As) ;- <br /> Tower Mart#876 <br /> BUSINESS SITE ADDRESS 103. CITY too. <br /> 14000 E. Hwy 88 Lockeford, CA <br /> FACILITY TYPE [!r1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 493. Is the facility located on Indian Reservation or 405 <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑Yes (R<G <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME Oar PHONE 40e. <br /> Tower Energy Group 310 538-8000 <br /> MAILING ADDRESS 4a9. <br /> 1983 W. 1901h St. Suite 100 <br /> CITY 410- STATE 4u. ZIP CODE 41z. <br /> Torrance CA 190504 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428.1, PHONE 428-2 <br /> Tower Energy Group (310) 538-8000 <br /> MAILING ADDRESS 428-3 <br /> 1983 W. 1901h St. Suite 100 <br /> CITY 4284 1 STATE 428-5 1 ZIP CODE 4284 <br /> Torrance CA 90504 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. 1 PHONE 415. <br /> Tower EnergyGroup (310) 538-8000 <br /> MAILING ADDRESS 416 <br /> 1983 W. 190th St. Suite 100 <br /> CITY 417 TSTATE 418. ZIP CODE 419. <br /> Torrance I CA 190504 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCYIDISTRICT ❑ 55.COUNTY AGENCY [16.STATE AGENCY 420. <br /> Ela 7.FEDERAL AGENCY 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44_ 13 g H Call the State Board of Equalization,Fuel Tax Division,if there aro questions. 421. <br /> VI.PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: 1.FACILITY OWNER ❑ 4.TANK OPERATOR 423 <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 certifythat the information provided herein is true,accurate and in full compliance with legal requirements. <br /> AP ANT NATURE DATE 4'-4 PHONE 4zs. <br /> 3/3/08 916 285-7402 <br /> APPLICANT NAME(print) 426. APPLICANT TITLE 4n <br /> Paul Chevalier Maintenance Manager <br /> UPCF UST-A Rev.(122007) <br />