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341e 0 <br /> ogowdl/Zr6/c <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUNDSTORAGETANK 3 T t v 1ANA dM-A-- <br /> OPERATING PERMIT APPLICATION-FACILITY INFO ATION �L�d��� FewrM <br /> of ?: -/gyp <br /> tOoe form acihty) <br /> IYPE OF ACTION ❑ I.NEW PERMIT ❑ 5.CHANGE OF INFORMATION 0 7.PERMANENT FACILITY CLOSURE. °00' <br /> (Cheek one item only) ❑ 3.RENEWAL PERMIT <br /> ❑ 6.TEMPORARY FACILITY CLOSURE. ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION 5fJ17 <br /> a <br /> TOTAL NUMBER OF USTs AT FACILITY FACILITY IDH n t. <br /> one (Agency Use Only) f% <br /> BUSINESSNAME: al umealIy «oaq-t>aax&umas qsl <br /> Residential Propertyy 3 <br /> BUSINESS SITE ADDRESS loa. CITY 1u4. <br /> 7457 Highway 26 Stockton 95215 <br /> FACILITY TYPE I.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403' Is the facility located on Indian Reservation or '105, <br /> 3.FARM ❑ 4.PROCESSOR ❑ 6-OTHER Trust lands? <br /> ❑Yes No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPF.RTV OWNER NAME eov. PHONE vmx <br /> 6 <br /> MAILING AUDRESS 91 708-7445 <br /> Nationwide Secure 5321 Swindon Road m <br /> CITY <br /> uo. STATE 4u. ZIP <br /> 4 n. <br /> Rocklin CODE <br /> CA 95765 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 42x-L PHONE 428-2 <br /> NA <br /> MAILINGADDRESS <br /> 42x-3 <br /> CITY 42x-3 <br /> STATE. +211-5 ZIP CODE eix-e <br /> TANK OWNER NAME. IV. TANK OWNER INFORMATION <br /> Nationwide Secure 414 1 <br /> /PHONE +is. <br /> MAILINGADDRESS <br /> 5321 Swindon Road me. <br /> CITY en. STATE. aix. ZIP CODE. <br /> Rocklin CA 95765 419' <br /> OWNERTYPE: ❑ 4.LOCAL AGENCYIDISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420 <br /> ❑ 7.FEDERAL AGENCY M R.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- Call the State Board of Equalization,Fuel Tax Division,itlhcreare questions. 42i. <br /> VI.PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: IM L FACILITY OWNER <br /> ❑ 4.TANK OPERATOR 423 <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) 4a6. <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICN: Ice if that the information rovided herein is true,accurate,and in fuH com lianas with le at requirements. <br /> APPLICA I ' TURE! <br /> • / DATE 424 <br /> 4z4. PIIONE 4zs. <br /> [CANT NA MEPont) ° - 916 708-7445 <br /> a^ <br /> Frank Dasmacci APPLICANTTITLE 427 <br /> Agent for Property <br /> UPCF UST-A Rev.(12/2007) <br />