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UNIFIED PROGRAM CONSOLIDATED FOR7v1 <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facility) 41 <br /> L 3 q l v�a <br /> TYPE OF ACTION ❑ 1.NEW PERMIT ® 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE lr/� / 9 <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 IDM <br /> '1, (Agency Use Only) <br /> BUSINESS NAME(Sarnem Facility Nam or DBA-Doing Business AsJ rya 2OOJ <br /> Fast and Eas Market 03 crrY J <br /> BUSINESS SITE ADDRESS Stockton 1\ ' Nl i%Q f HEALTH <br /> 244 W. Hardin Wa is the ry � � � � ,o5 <br /> FACILITY TYPE ® 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION a03 Tmssshm <br /> t landst ❑ate Yes ® 2.No <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER <br /> II. PROPERTY OWNER INFORMATION <br /> 402. PHONE 408. <br /> PROPERTY OWNER NAME <br /> Julie Kim, Nara Bank 213 233-1860 <br /> 409. <br /> MAILING ADDRESS <br /> 3731 Wilshire Blvd., Suite 1000 410 411 ZIP CODE 412 <br /> . STATE <br /> CITY <br /> Los Angeles CA 90010 <br /> IH. TANK OPERATOR INFORMATION <br /> 428-1. PHONE 428 2. <br /> TANK OPERATOR NAME <br /> Tanks are not currently in operation awaiting temporary closure ( ) <br /> status. 42&3 <br /> MAILING ADDRESS <br /> CITY 4211-4, STATE <br /> 428-s. ZIP CODE 428-0. <br /> IV. TANK OWNER INFORMATION <br /> TANKOWNERNAME 414. PHONE 415. <br /> same as owner above ( ) <br /> 41e. <br /> MAILING ADDRESS <br /> CITY 417. STATE 41& ZIP CODE 419_ <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420 <br /> El 7.FEDERAL AGENCY ® 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- <br /> Call[he Stale Board ofEqualizatioq Fuel Tax Division,ifthere are questions. 421 <br /> VI. PERMIT HOLDER INFORMATION <br /> 42J. <br /> Issue permit and send legal notifications and mailings to: ® 1.FACILITY OWNER [34.TANK OPERATOR <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required for Public Agencies Only) 406- <br /> VIL APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that the information provided herein is true,accurate,and in full com fiance with legal requirements. <br /> APPLICANT SIGNATURE DATE 41 1 1 Cot424- PHONE 425. <br /> UPCF UST-A Rev.(12/2007)-113 w .unidocs.org <br /> w <br />