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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 40n. <br /> (Check one item only) ❑ 3.RENEWAL PERMIT <br /> ❑ 6.TEMPORARY FACILITY CLOSURE ® 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404 FACILITY ID# 1 <br /> 1 (Agency Use Only) - <br /> BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3. <br /> Food Mark Gasoline <br /> BUSINESS SITE ADDRESS 103. CITY 104. <br /> 2185 E. Fremont Stockton <br /> FACILITY TYPE Z 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403. Is the facility located on Indian Reservation or 405. <br /> ❑ 3.FARM ❑ 4.PROCESSOR Q 6.OTHER Trust lands? ❑ 1.Yes ® 2.No <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 408. <br /> Jojinder Lal 209 937-0195 <br /> MAILING ADDRESS any. <br /> 840 Dupont Drive <br /> CITY 410• STATE 411. ZIP CODE 412. <br /> Stockton CA 95210-2018 _ <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. pgONE 429-2. <br /> Ram Rattan (209) 941-2264 <br /> MAILING ADDRESS 428-3. <br /> 840 Dupont Drive <br /> CITY 428.4• STATE 428-5• 1 ZIP CODE 428-6. <br /> Stockton CA 95210-2018 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414, PHONE 415. <br /> Joinder Lal (209) 937-0195 <br /> MAILING ADDRESS 416. <br /> 840 Dupont Drive <br /> CITY Ori. STATE als. ZIP CODE 419. <br /> Stockton I CA 95210-2018 <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- 1 1 Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421. <br /> VI. PERMIT HOLDER INFORMATION <br /> Issuepemit and send legal notifications and mailings to: ❑ 1.FACILITY OWNER 4.TANK OPERATOR 423. <br /> I9 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required for Public Agencies Only) 406. <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that the information provided herein is true,accurate,and in full compliance with legal requirements. <br /> APPLICANT SJNATURE DA'L'E ata. 1 PHONE 425. <br /> rll A ol 9/15/2008 209 941-2264 <br /> APPLICANT NAME(print) 426. APPLICANT TITLE 427 <br /> Ram Rattan Manager <br /> UPCF UST-A Rev.(17/2007)-1/2 www.unidocs.org <br />