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of <br /> An <br /> ,9L <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION- FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION ❑ 1.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 k <br /> 3 Agency <br /> en Use onl <br /> BUSINESS NAME(S...FACILrrY NAME or DBA—Doing Businps As) 3. <br /> George's Mini Mart <br /> BUSINESS SITE ADDRESS 101 CITY 109. <br /> 18662 N HWY 88 LOCKEFORD <br /> FACILITY TYPE Z L MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION ma. Is the facility located on Indian Reservation or 405. <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑ Yes ❑No <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407, PHONE 408, <br /> George Galasatos 209 482-5958 <br /> MAILING ADDRESS 409 <br /> 18662 N HWY 88 <br /> CITY 410. STATE 411. ZIP CODE 412, <br /> LOCKEFORD CA 95237 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. PHONE 428-2 <br /> RUPINDER PADDA (209) 814-5576 <br /> MAILING ADDRESS _72_9_3 <br /> 18662 N HWY 88 <br /> CITY 428 STATE 428-5 ZIP CODE 42M <br /> LOCKEFORD CA 95237 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> George Galasatos (209) 482-5958 <br /> MAILING ADDRESS 416. <br /> 18662 N HWY 88 <br /> CITY do 1 STATE 418, ZIP CODE 419. <br /> LOCKEFORD CA 95237 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY ® 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 3 1 2 4 1 7 1 8 1 1 Call the State Board of Equalization,Fuel Tar Division,if there are questions. 421. <br /> VI.PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: Z I.FACILITY OWNER ❑ 4.TANK OPERATOR 423 <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) 406. <br /> VII. APPLICANT SIGNATURE GL2 <br /> CE TIFIC : Icer 'f that the information provided herein is true,accurate,and in full compliance with legal re uiremen <br /> APPL=E DATE 424- PHONE „.425. <br /> 05-01-10 209 814-5576 <br /> APPLICANT NAME(print) 426 1 APPLICANTTITLE C� 427 <br /> Ru inder Padda SEC <br /> FIA <br /> complefed <br /> IJPGF UST-A Rev.(12/2007) <br />