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IED PROGRAM CONSOLIDATED FORW <br /> E: <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 400" <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 /> 3 (Age- Use Only) <br /> BUSINESS NAME(Same as FACB.rrY NAME or DBA-Doing Business As) , <br /> VALLEY SERVICE STATION <br /> BUSINESS SITE ADDRESS 103. CITY 104 <br /> 16 East Harding Way Stockton <br /> FACILITY TYPE ® 1.MOTOR VEHICLE FUELING 403. 1-. 405 <br /> ❑ 2.FUEL DISTRIBUTION Is the facility ated on in ian Reservation or <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? Yes ANo <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. r(209) <br /> NE 408 <br /> ABRAHAM CYRUS 466-9516 <br /> MAILING ADDRESS 409 <br /> 16 EAST HARDING WAY <br /> CITY 410. 1 STATE 4u. <br /> ZIP CODE 412 <br /> Stockton CA 95204 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. 1 PHONE 428-2 <br /> ABRAHAM CYRUS (209)466-9516 <br /> MAILING ADDRESS 428-3 <br /> 16 EAST HARDING WAY <br /> CITY 428 STATE 428-s <br /> ZIP CODE 428-6 <br /> STOCKTON CA 195204 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> ABRAHAM CYRUS (209)466-9516 <br /> MAILING ADDRESS 416 <br /> 16 EAST HARDING WAY <br /> CITY 4n. STATE 418. 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 ® 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- d 1f 7 1 t 16 3 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: ® 1.FACILITY OWNER423 <br /> ❑ 4.TANK OPERATOR <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE406 <br /> (Required For Public Agencies Only) <br /> VH.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 424. PHONE 425. <br /> APPLICANT NAME(print) 426. APPLICAN TITLE 4z� <br /> 4169�t��-r-r C R(/s <br /> UPCF UST-A Rev.(12/2007) \ <br />