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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUNDSTORAGETANK <br /> OPERATING PERMIT APPLICATION—FACILITY INFORMATION <br /> (CMc inrm per facili;}i <br /> TYPE OF-ACTION 1,NEW PERMIC ❑ 5.CHANGE OF INFORMATION ❑ 7.PI.RA(ANENT FACILITY CLOSI:It] <br /> t(h"C""`"""inil)1 ❑ 3.RENEWAL PERMIT a (� 'f1:Mi'ORARY FACILITY CLOSURE ❑ 9.TRANSFIIR PFRMI I <br /> L FACILITY INFORMATION <br /> TOTAL.NUM RFR OF USTs AT FACILITY 4a. PA('11.1.1Y 11)4 _ <br /> 3 (4gene) Rsr Otd}9 1 ' <br /> r <br /> BUSINESS NAMF(swe..rrcum-SAW:m DDA- <br /> EAST HARNEY ARCO <br /> BUSINESS SITE ADDRESS let CITY 1w <br /> 255 E. HARNEY LANE LODI <br /> au: <br /> FACILITY TYPE 0 1.M0'1'OR VIiI11CLE FUELING [32,FUEL DISi;71ON Is the fTRIBacduy located on Indian Reservation to '05 <br /> ❑ 3.FARR1 ❑ 4 PR(K'ESSOR 0 6.OILIER <br /> Trust tands+ ❑Yes ENO <br /> Il. PROPERTY OWNER INFORMATION <br /> PR(WER'IN OWNER NAME - 40 TPI A'� <br /> KEN DHARNI 916 '115-6425 <br /> ,.w <br /> MAILING ADDRESS <br /> 6698 MACK ROAD <br /> C'1TY 410 STATE 4t1 ZIPCODE 412 <br /> SACRAMENTO CA 95821 <br /> IIL TANK OPERATOR INFORMATION <br /> 'IANK OPERATOR NAME A'+-1 PBCINE A='' <br /> SAME AS ABOVE <br /> 4:0d <br /> MAILING ADDRESS <br /> CITY 4284 STATE ur 11 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 1 PHONE <br /> SAME AS ABOVE { <br /> 41.. <br /> MAILING ADDRESS <br /> CIIY 41: 1 STATE. 4u ZIP C'OU6 a19 <br /> OWNER TYPE. ❑ 4.LOCAL AGENCWDISTRIC:T ❑ 5.COUNTY AGENCY {] 4.STATE AGENCY Alli, <br /> ❑ 7.FEDERAL.AGENCY g.NON-OOVFRNMFN'f <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> + TY(TK)LIQ 44- 0 an <br /> ii-all the Stale Board of Equalieatinn,Fuel Tai Uivismn,if there arc yvestions <br /> VI.PERMIT HOLDER INFORMATION <br /> IsATOR <br /> sue Permit and send legal rmtitisarinns and mailings to: 1.TANKOWNERLLITY ❑ 4.TACIL11Y PIRA <br /> ❑ 3.TANK OWNER ❑ 3.FACILITY OPERr1TOR <br /> SUPERVISOR OF DIVISION.SFCTION,OR Of+ICE.(Required For Public Agencies Only) <br /> VII.APPLICANT SIGNATURE <br /> C'F:RTIFIGt'f10N: 1 etri(fs'th+(the information rarided herein is true.ateurate,and in full cam lionce eitb legal rer uirewent•. <br /> APPLICANT SICLNATURE• DATE A-A PHONC: <br /> APPLIC'ANTNAME(pont) 4=R APPLICANTTITIT 'rr <br /> k + P R ' S I tizns1 <br /> UPCF IEST•A Rev.(1212067) <br />