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UNIFIED PROGRAM CONSOLIDATED FORM <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 aoo. <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 404, FACILITY ID# _ 1 <br /> 3 (Agency Use Only) a g <br /> BUSINESS NAME(Same as FACILrrY NAME or DBA-Doing Business As) 3 <br /> Arco AM/PM <br /> BUSINESS SITE ADDRESS 103 CITY 104, <br /> West Valpico Rd Tracy <br /> FA I ITY TYPE ® 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403. Is the facility located on Indian Reservation or 405, <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑Yes ®No <br /> II. PROPERTY OWNER INFO!NATIO <br /> PROPERTY OWNER NAME `r^I / __ 407 PHONE 408. <br /> c. V '11� <br /> MAILING ADDRESS 409. <br /> d yc-tS �� 5S6 ��• Sic <br /> CITY 1 n 410. STATE all. ZIP CODE 411 <br /> CA I 9rs29 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. PHONE 428-2 <br /> Pacific West Petroleum Inc . ( 925 689-0557 <br /> MAILING ADDRESS 428-3 <br /> 3400 Willow Pass Road <br /> CITY 428-4 STATE 428-5 ZIP CODE 428-6 <br /> Concord I CA 94519 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> Pacific West Petroleum Inc. ( 925 ) 689-0557 <br /> MAILING ADDRESS 416. <br /> 3400 Willow Pass Road <br /> CITY 417, STATE 418. ZIP CODE 419. <br /> Concord CA 94519 <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 JK)HQ 44- Call the State Board of Equalization,Fuel Tax Division,if there are questions. !_ <br /> VI.PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: ® 1.FACILITY OWNER ❑ 4.TANK OPERATOR <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> 400 <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I ce t tjj information provided herein is true,accurate,and in full compliance with legal re uirements. <br /> APPL TURF DATE 424. 1 PHONE 425. <br /> 1124 �f 925 689-0557 <br /> APPLICANT NAME(print) <br /> 426. APPLICANT TITLE ''' <br /> Property Owner <br /> UPCF UST-A Rev.(12/2007) ampleted <br /> 1 <br />