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UNIFIED PROGRAM CONSOLIDATED FORM 101-?.ttq <br /> UNDERGROUND STORAGE TANK KYR <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATI <br /> (One form per facility) <br /> TYPE OF ACTION Ell.NEW PERMIT CHANGE OF INFORMATION ® 7.PERMANENT FACILITY CLOSURE i00�I I I IJ <br /> (Check one item only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION ew <br /> rOTAL NUMBER OF USTs A3T FACILITY °04' FACILITY <br /> (Ager <br /> BUSINESS NAME(s4mea FACILITY NAME« eA-Min Bpi.M) <br /> Caltrans U <br /> BUSINESS SITE ADDRESS 101 CITY too <br /> 14800 8 Rig ay 99 Manteca <br /> FACILITY TYPE ❑ I.MOTOR EHICLE FUELING [12.FUEL DISTRIBUTION 40J Is the facility located on Indian Reservation or 4os. <br /> ❑ 3.FARM 4.PROCESSOR El 6-OTHER Tout lands? ❑Yes ®No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 1 PHONE 408. <br /> Caltr ns 209 948-3980 <br /> MAILINGADDRESS/6 <br /> 3 2663 Arch Road, Suite 5007 <br /> CITY / 410. 1 STATE 411 1 ZIP CODE d12 <br /> Stockton CA 95215 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 42 1. PHONE 428-2 <br /> As Bove <br /> MAILING ADDRESS \ d2 3 <br /> CITY 4184 1 STATE 42 5 ZIPCODE 4186 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME As Above 414_ PHONE 415. <br /> MAILING ADDRESS 416. <br /> CITY 417 1 STATE 418, ZIPCODE 419. <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- Call the State Board of Equaliration,Fuel Tax Division,if there are questions. 421. <br /> VI. PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: ❑ I.FACILITY OWNER ❑ 4.TANK OPERATOR <br /> sn <br /> E3 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> 06 <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) <br /> VII. APPLICANT SIGNATURE <br /> CERTIFICATION I ertify that the information provided herein is true,accurst and in full compliance with legal requirements. <br /> APPLICANT SIGNA R DATE10-2/7-13 424, PHONE 425. <br /> (951-808y8585 <br /> APPLICANT NAME(pri ) 426 APPLICANT TITLE 427 <br /> Tim Lane Director/Ageny <br /> UPCF UST-A Rev.(12/2007) <br />