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I IED PROGRAM CONSOLIDATED FOIN <br /> I <br /> UNDERGROUND STORAGE TANK 9 � <br /> OPERATING PERMLIT APPLICATION-FACILITY INFORMATION u, <br /> (One form per facility) <br /> TYPE OF ACTION X L NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400 <br /> (Check one item only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404. FACILITY ID# 1' <br /> 3 (Agency Use Only) 1 1 <br /> BUSINESS NAME(Same as PACMUYNA or DBA-Doing Business As) 3. <br /> Tower# 876 <br /> BUSINESS SITE ADDRESS 103. CITY 104, <br /> 14000 E. Hwy 88 Lockeford <br /> FACILITY TYPE x 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403. Is the facility located on Indian Reservation or 405. <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑Yes x No <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 4°]. PHONE 408. <br /> Tower Energy Group 916-285-7402 Ext 104 <br /> MAILING ADDRESS 409. <br /> 1983 West 190th Street <br /> CITY 410, STATE 411. ZIP CODE 412. <br /> Torrance CA 90504 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1 PHONE 428.2 <br /> Tower Energy Group 916-285-7402 Ext 104 <br /> MAILING ADDRESS 42x3 <br /> 1983 West 190th Street <br /> CITY 4284 STATE 428-5 ZIP CODE 42" <br /> Torrance CA 90504 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415, <br /> Tower Energy Group 916-285-7402 Ext 104 <br /> MAILING ADDRESS 416. <br /> 1983 West 190th Street <br /> CITY 417. STATE 418. ZIP CODE 419. <br /> Torrance CA 90504 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY X 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 7� U Call the State 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: ❑ 1.FACILITY OWNER ❑ 4.TANK OPERATOR 423 <br /> X 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 information provided herein is true,accurate,and in full compliance with legal requirements. <br /> APPL SIGNATURE DATE 424 PHONE . _ 425. <br /> $ a -o 916 373-1166 <br /> APPLICANT NAME(print) 426. APPLICANT TITLE 427 <br /> Dulcinea Webb Com Iiance.Mana er "` <br /> UPCF UST-A Rev.(12/2007) [ ' completed <br />