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AMUrI <br /> - y <br /> 24-10 <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 115.CHANGE OF INFORMATION [17.PERMANENT FACILITY CLOSURE 400 <br /> (Check one item only) ® 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> o <br /> TOTAL NUMBER OF U <�STs AT FACILITY FACILITY ID n _ - p <br /> 1 (Agency Use O [y) <br /> 3. <br /> BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) <br /> FLAG CITY ARCO/SUBWAY 103. CITY 1� <br /> BUSINESS SITE ADDRESS LODI, CA 95242 <br /> 14931 FLAG CITY BLVD. 405_ <br /> FACILITY TYPE E 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 4°3. Is the facility located on Indian Reservation or <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑ I.Yes E 2.No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 408- <br /> YOUSIF HALLOUM 209 764-1165 <br /> MAILING ADDRESS <br /> 14931 FLAG CITY BLVD <br /> CITY 410- STATE 411, ZIP CODE 412. <br /> LODI I CA 95242 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 42sr PHONE a2s-z. <br /> YOUSIF HALLOUM (209) 764-1165 <br /> MAILING ADDRESS 42ea. <br /> SAME AS ABOVE <br /> CITY 428-4. 1 STATE 428-5. ZIP CODE 428 . <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415, <br /> YOUSIF HALLOUM (209) 764-1165 <br /> MAILING ADDRESS 416. <br /> SAME AS ABOVE <br /> CITY 417 1 STATE 418. ZIPCODE 419, <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420_ <br /> ❑ 7.FEDERAL AGENCY E 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 1013171710191 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: E 1.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 <br /> CERTIF ATI 1 cliftify that the information provided herein is true,accurate,and in full compliance with legal re uireme <br /> APPLIC SI AT DATE 424- PHONE 425. <br /> 6/23/2010 (209) 764-1165 M <br /> APPLI T YAYV( rint) 426. APPLICANTTITLEca42z <br /> YOUSIF LLOUM OWNER <br /> UPCF UST-A Rev.(12/2007)-1/2 www.unido 1t�1- <br /> R '�1�& LIJ <br />