Laserfiche WebLink
��[ rl ' <br /> ED PROGRAM CONSOLIDATED FOR 125 l will,81- <br /> UNDERGROUND STORAGE TAM{ fu IZ <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION l <br /> (One form per facili ) <br /> TYPE OF ACTION ❑ L NEW PERMIT ® 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILI'T'Y CLOSURE 400' <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 4°4' FACILITY ID# <br /> 3 A Use 0*) <br /> J CP <br /> BUSINESS NAME(Same as FACUM NAW or DBA-Doing Business As) 3. <br /> VALLEY SERVICE STATION <br /> BUSINESS SITE ADDRESS 103. CITY 104. <br /> 16 East Harding Way Stockton <br /> FACILITY TYPE ® 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403. Is the facility'^^ated on In ian Reservation or 405. <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? Yes ALNo <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 408, <br /> ABRAHAM CYRUS (209)466-9516 <br /> MAILING ADDRESS P- () D� I Z 4W. <br /> CITY rr 1, 244110. 1 STATE all. ZIP CODE 412. <br /> Stac"on Los L J CA A5204-- 9 50 <br /> M. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1 PHONE 428-2 <br /> ABRAHAM CYRUS (209)466-9516 <br /> MAILING ADDRESSP, 0 I s � � I 7� 428-3 <br /> Y <br /> CITY 428-4 1 STATE 428-5 1 ZIP CODE 428-6 <br /> STOCKTON CA 95204 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. 1 PHONE 415 <br /> ABRAHAM CYRUS (209)466-9516 <br /> MAILING ADDRESS P- fj `' 416. <br /> CITY / `J X 417. 1 STATE ats. ZIP CODE 419, <br /> STOCKTON CA 95204 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420 <br /> ❑ 7.FEDERAL AGENCY ® S.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 10 'f 7 It 6 13 1 Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421 <br /> VI.PERMIT HOLDER INFORMATION <br /> Issue it and send legal notifications and mailings to: ® 1.FACILITY OWNER 423 <br /> perm g gs ❑ 4.TANK OPERATOR <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 /> CERTIFICATION: I certify that the information provided herein is true,accurate,and in full compliance with legal requirements. <br /> APPLICANT SIGNATURE / DATE aza. P 425. <br /> J_/ <br /> APPLICANT NAME(print) 426. APPLICANt TITLE e 427 <br /> C R(/s <br /> r <br /> f. <br /> UPCF UST-A Rev.(12/2007) ` <br />