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0 1cf4 <br /> UNIFIED PROGRAM CONSOLIDATED F47TI 911PT001 <br /> UNDERGROUND STORAGE TANK 'n I <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION ❑ L NEW PERMIT 1F'5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400. <br /> (Check one item only) 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> L FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY °04- FACILITY ID# 1, <br /> 3 A enc UseOrt! <br /> BUSINESS NAME(Same as FACILITY NAME or DBA—Doing Business As) <br /> Spirit Gasoline <br /> BUSINESS SITE ADDRESS 103, CITY 104. <br /> 1250 North Wilson Way Stockton <br /> FACILITY TYPE Z I.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 Z No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 40a <br /> MAILING ADDRESS - 409. <br /> CITYNnA n ` 410. STATE 411. ZIP CODE 1) -0& 411 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1- PHONE 428-2 <br /> Joinder Lal (209) 547-1700 <br /> MAILING ADDRESS 4283 <br /> 840 Dupont Drive <br /> CITY 428-4 STATE 428-5 ZIP CODE 428-6 <br /> Stockton CA 95210 <br /> IV. TANK OWNER INFORMATION <br /> TANKOWNERNAME 414 1 PHONE 415. <br /> Joinder Lal &T �p (209) 547-1700 <br /> MAILING ADDRESS 416. <br /> 840 Dupont Drive <br /> CITY 4)7 1 STATE 418, 1 ZIP CODE 419. <br /> Stockton CA 95210 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420_ <br /> ❑ 7.FEDERAL AGENCY Z 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> .� TY(TK) HQ 44- Call the State Board oC Rqualization,Fuel Tax Division,if there are questions. °`l <br /> VI. PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: ❑ 1.FACILITY OWNER Z 4.TANK OPERATOR 423 <br /> Z 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) 406. <br /> VII. APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that the information provided herein is true,accurate,and in full compliance with legal requirements. <br /> APPLICANTSIGNATURE DATI 424 PHONE 425. <br /> ;m 9/16/2009 209) 547-1700 <br /> APPLICANT NAME(print) 426 APPLICANT TITLE 427 <br /> Joinder Lal Owner/Operator <br /> UPCF UST-A Rev.(12/2007) <br />