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D � u <br /> IFIED PROGRAM CONSOLIDATED FOM qui a� l <br /> UNDERGROUND STORAGE TANK o' � al <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) <br /> ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404. <br /> FACILITY ID# <br /> 3 (Agency Use Only)... <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) , <br /> Komal Bros Inc. (DBA)76 Express Tiger#1 <br /> BUSINESS SITE ADDRESS 103, CITY 104. <br /> 5777 S. French Camp Rd Stockton <br /> FACILITY TYPE ® 1.MOTOR VEHICLE FUELING 403. 405. <br /> ❑ 2.FUEL DISTRIBUTION Is the facility located on Indian Reservation or <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑Yes ®No <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 408. <br /> Komal Bros Inc. (209) 9834781 <br /> MAILING ADDRESS 409. <br /> 5777 S. French Camp Rd <br /> CITY 410, 1 STATE 411. ZIP CODE ail. <br /> Stockton Ca 95206 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. PHONE 428-2 <br /> Kornai Bros Inc. (209) 983-4781 <br /> MAILING ADDRESS 428-3 <br /> 5777 S. French Camp Rd. <br /> CITY 428-4 STATE 428-5 ZIP CODE 428-6 <br /> Stockton Ca 95376 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> Komal Bros Inc. (209) 983-4781 <br /> MAILING ADDRESS 416 <br /> 5777 S. French Camp Rd <br /> CITY 417. STATE 418. ZIP CODE 419. <br /> Stockton Ca 95206 <br /> OWNER TYPE: z1jr-4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY <br /> ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY 5K 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 1 0 1 4 1 5 1 3 1 6 1 7 1 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: 4'-3 <br /> P' g b ® 1.FACILITY OWNER ❑ 4.TANK OPERATOR <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) <br /> 406 <br /> VII.APPLICANT SIGNATURE <br /> CERT FIC N: I certify that the information provided herein is true,accurate,and in full compliance with legal requirements. <br /> APPLI ANT G ATURE DATE / 424. PHONE 4'S, <br /> 72 <br /> APP AN ' (print) 426. ( ( ^� <br /> 1 �1 APPLICANT TITLE <br /> !� c� 147t <br /> 's a <br /> UPCF UST-A Rev.(12/2007) <br />