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'I.. <br /> JINIFIED 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 i1' <br /> /Check o 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) - 0 - 3 7 0 7 <br /> BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) <br /> AHMED'S SONS INCORPORATED <br /> BUSINESS SITE ADDRESS 10. CITY Ia. <br /> 1257 WEST YOSEMITE AVENUE MANTECA <br /> FACILITY 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? ❑ 1.Yes ® 2.No <br /> IL PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 401, PHONE 408 <br /> SAN JOAQUIN VALLEY PROPERTIES, LLC 209 823-1724 <br /> MAILING ADDRESS 48-9. <br /> P.O. BOX 2524 <br /> CITY 410 1 STATE 411_ ZIP CODE 412, <br /> MANTECA CA 95336 <br /> M. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. PHONE 428-2. <br /> SAN JOAQUIN VALLEY PROPERTIES,LLC (209) 823-1724 <br /> MAILING ADDRESS 428-3_ <br /> P.O. BOX 2524 <br /> CITY 42" 1 STATE 428-5. ZIP CODE 429 <br /> MANTECA CA 95336 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> SAN JOAQUIN VALLEY PROPERTIES,LLC (209) 823-1724 <br /> MAILING ADDRESS 116 <br /> P.O. BOX 2524 <br /> CITY 42 STATE 418, 1 ZIPCODE 419_ <br /> MANTECA CA 95336 <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(TK)HQ 44- 1014121710121 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: ❑ 1.FACILITY OWNER ❑ 4.TANK OPERATOR <br /> 23 <br /> ® 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Requiredfor Public Agencies Only) 4 406 <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that the information provided herein is true,accurate,and in full com liance with legal requirements. <br /> APPLICANT SIGNATURE DATE Ql PHONE 425 <br /> (209) 823-1724 <br /> APPLICANT NAME(print) 426. APPLICANT TITLE 4'--� <br /> NADEEM AHMED MANAGER <br /> UPCF UST-A Rev.(122007)-12 w .unidocs.org <br />