Laserfiche WebLink
/ AA I>J <br /> to <br /> L. IFIED PROGRAM CONSOLIDATED FORM aha r0 <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 4D0. <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 004' FACILITY ID ii <br /> 3 (Agency(Ise Only) <br /> BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3. <br /> Tower Market# 886 <br /> BUSINESS SITE ADDRESS 103. CITY 104. <br /> 1434 W Yosemite Ave. Manteca,Ca 95337 <br /> FACILITY TYPE N 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 03. Is the facility located on Indian Reservation or 405. <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑ 1.Yes N 2.No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 409. <br /> Tower Energy Group 310 538-8000 <br /> 409. <br /> MAILING ADDRESS <br /> 1983 W. 190t' St. <br /> CITY 410. STATE 411. ZIP CODE 412. <br /> Torrance CA 90504 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. PHONE 4za-z. <br /> Tower Energy Group (916) 285-7402 <br /> 428-3. <br /> MAILING ADDRESS <br /> 20 Goldenland Court <br /> CITY <br /> 4284. STATE 428-5. ZIP CODE 428-6. <br /> Sacramento CA 95834 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415, <br /> Tower Energy Group (310) 538-8000 <br /> MAILING ADDRESS 416. <br /> 1983 W. 1901h St. <br /> CITY 417. STATE 418. 1 ZIP CODE 419. <br /> Torrance CA 90504 <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- 3 8 4 4 0 Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421. <br /> VI.PERMIT HOLDER INFORMATION <br /> 423. <br /> Issue permit and send legal notifications and mailings to: El 1.FACILITY OWNER N 4.TANK OPERATOR <br /> ❑ 3.TANK OWNER ❑ S.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required for Public Agencies Only) 406. <br /> VII. APPLICANT SIGNATURE <br /> CERTIFICATION: I certift that the information prgvided herein is true accurate and in full compliance with legal requirements. <br /> APPLICANT SIGNATURE � DATE 424. PHONE 4zs. <br /> 1/5/2010 916 285 7402 42 <br /> APPLICANT NAME(p nt) 026. APPLICANT TITLE <br /> Paul Chevalier Maintenance Manager <br /> UPCF UST-A Rev.(12/2007)-1/2 www.unidoes.org <br />