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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 ❑ I.NEW PERMIT ❑ 5.CHANGE OF INFORMATION ® 7.PERMANENT FACILITY CLOSURE <br /> (Check one item only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFERPERMrr <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTS AT FACILITY 404- FACILITY ID H <br /> I A en Use onl — — <br /> BUSINESS NAME(S..n FACn1TY NAME a DBA-Doing Businu4 An 1. <br /> CALTRANS Highway 26 Right of Way,State of California <br /> BUSINESS SITE ADDRESS im. CITY 101 <br /> N.E.corner of 19107 East Highway 26(Caltrans Right of Way) Linden <br /> FACILITY TYPE ® 1.MOTOR VEHICLE FUELING El 2.FUEL DISTRIBUTION �' Is the facility located on Indian Reservation or a05' <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑Yes ®No <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 408. <br /> State of California(Caltrans) (559)445-6378 <br /> MAILING ADDRESS q09 <br /> 855 M Street,Suite 200 <br /> CITY 410. STATE 411 ZIP CODE 412, <br /> Fresno CA 93721 <br /> HI. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1, PHONE 428-2 <br /> Unknown ( ) <br /> MAILING ADDRESS 429a <br /> CITY 4284 1 STATE 428-3 1 ZIP CODE 429.6 <br /> IV. TANK OWNER INFORMATION <br /> TANKOWNERNAME 414 PHONE 415 <br /> State of California(Caltrans) (SSA)445-6378 <br /> MAILING ADDRESS 416 <br /> 855 M Street,Suite 200 <br /> CITY 41T 1 STATE. 4u. ZIP CODE 419 <br /> Fresno CA 93721 , <br /> OWNER TYPE: ❑ 4.LOCAL AGENCYJDISTRICT ❑ 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- 1 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: ® L FACILITY OWNER ❑ 4.TANK OPERATOR 423 <br /> ❑ 3.TANK OWNER ❑ S.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only)Clem Goewert <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 °24. PHONE 425_ <br /> 10/14/2( 14 916) a5z-9118 <br /> APPLICANT NAM print) 426 1 APPLICANT TITLE. 427 <br /> Bob M. Kimball RME,Authorized Agent for Caltrans <br /> UPCF UST-A Rev.(12/2007) <br />