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N IED PROGRAM CONSOLIDATED F 9 <br /> UNDERGROUND STORAGE TANK 3 <br /> [:::OPTETING' <br /> PERMIT APPLICATION—FACILITY INFORMATION <br /> TYPE OF ACTION (One form per f ility) <br /> ❑ 1.NEW PERMIT El 5.CHANGE OF INFORMATION <br /> (Check one item only) ® 7.PERMANENT FACILITY I SURE 400 <br /> ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9,TRANSFER PERMIT III q <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 400. <br /> FACILITY ID# <br /> 1 <br /> A en nl .�S $ <br /> BUSINESS NAME(s,m44,rnco.try NAAni or oaA- Use O <br /> Doing auainesa Aa <br /> Dutra-Comenzind Pro e , <br /> BUSINESS SITE ADDRESS 9' 7 <br /> 2131 East Louise Avenue 03 CITY <br /> FACILITY TYPE the <br /> fa <br /> ❑ 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403' 405. <br /> Is the facility located on Indian Reservation or <br /> ❑ 3.FARM ❑ 4.PROCESSOR ® 6.OTHER Trust lands? ❑Yes ®No <br /> PROPERTY OWNER NH. PROPERTY OWNER INFORMATION Q/ <br /> AME <br /> Shirley Dutra Trust and Sande Comenzind 407 PHONE �l <br /> ,W ADDRESS 623 776-6684 <br /> 1800 South McKinle Avenue 409 <br /> CITY <br /> 410. STATE 411. ZIP CODE <br /> Manteca CA 41z. <br /> 95337 <br /> TANK OPERATOR NIII. TANK OPERATOR INFORMATION <br /> AME <br /> Unknown 429-1. PHONE <br /> 426-2 <br /> MAILING ADDRESS ( ) <br /> 429-3 <br /> CITY 42s-0 <br /> STATE az9-s ZIP CODE 42M <br /> IV. TANK OWNER INFORMATION <br /> TANKOWNERNAME 414. PHONE 415. <br /> ShirleyDutra Trust and Sande Comenzind (623) 776-6684 <br /> MAILING ADDRESS 4 s <br /> j9 1894 South McKinleyAvenue <br /> CITY ay. STATE ala. 1 ZIP CODE 419, <br /> CA 95337 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 4M <br /> ❑ 7.FEDERAL AGENCY ® 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 1 1Call the State Board of Equalization,Fuel Tax Division,if there are questions. a21 <br /> VI.PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: ❑ 1.FACILITY OWNER ❑ 4.TANK OPERATOR 423 <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) 40s. <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 SI TU DATE 424. PHONE 425. <br /> 4/30/2014 209)467-1006 <br /> APPLICANT NAME(print) 426 1 APPLICANT TITLE 427 <br /> Robert Marty Agent for ShirleyDutra Trust and Sande Comenzind <br /> UPCF UST-A Rev.(12/2007) <br />