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z Z71 <br /> UNIFIED PROGRAM CONSOLIDATED FORM �� C <br /> UNDERGROUND STORAGE Ti ��0 "/ 2 <br /> OPERATING PERMIT APPLICATION-FAC ILITYINFO ATION CJ�d�d��� <br /> (One form d acihty) <br /> TYPF:OF ACTION ❑ I.NEW PERMIT ❑ 5.CHANGE OF INFORMATION ® 7.PERMANENT FACILITY CLOSURE. °ao <br /> (Checkone;mmonly) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE <br /> ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION 5a o2 Idw <br /> TOTAL NUMBER OF USTs AT FACILITY °n0' FACILITY <br /> one (Agency Ure Only) p f"Y <br /> BUSINESS NAME(se,N"-lAllLny NAME munA-Wing 1pa;�xvr ul 7. av(lb <br /> Residential Property <br /> BUSINESS SITE ADDRESS 102. CITY iu°. Ie <br /> 7457 Highway 26 <br /> Stockton 95215 Pole <br /> FACILITY TYPE ® I.MOTOR VEHICLE FUELING [12.FUEL DISTRIBUTION 13' Is the facility located on Indian Reservation or °05' <br /> ® 3.FARM El 4.PROCESSOR 6.OTHER Trust lands? ❑Yes ®No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 I PHONE Ons, <br /> 916 708-7445 <br /> MAILING ADDRESS uw <br /> Nationwide Secure 5321 Swindon Road <br /> CITY 410. 1 STATE 411. ZIP CODE az. <br /> Rocklin CA 95765 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 41A-1. PHONE 428--2 <br /> NA <br /> MAILING ADDRESS 4287 <br /> - <br /> CITY a2n-s STATE. 42w5 1 ZIPC'ODF. 429-6 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME. 414. PHONE 41 s. <br /> Nationwide Secure <br /> MAILINGADDRESS 5321 Swindon Road 71-6— <br /> CITY Rocklin 417. 1 STATE95765 <br /> CA 419. ZIPCODF. 419. <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ S.COUNTY AGENCY ❑ 6.STATE AGENCY ago, <br /> ❑ 7.FEDERAL AGENCY ® B.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 1 1 1 1 1 1 Call the Stale Board of NWIliration,Fuel Tax Division,if there arc questions. 421. <br /> VI.PERMIT HOLDER INFORMATION <br /> Issue pennilandsend legal notifications andmailingsto: ® L.FACILITY OWNER ❑ 4.TANK OPERATOR 42I <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) 406 <br /> VII.APPLICANT SIGNATURE <br /> CERTIFIC N: 1 cc i!fj that the informationrovided herein is true accurate and in full compliance With Ie 1 reuirements. <br /> APPLICA 1 ' TUREi I DATE424_ PI IONF. 4zs. <br /> 01/19/2010 <br /> 9161 70B-7445 <br /> ICANT NAME(......) 42a. pppLICANTTITLE 427 <br /> Frank Dasmacci Agent for Property <br /> UPCF UST-A Rev.(12/2007) <br />