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ens <br /> WFIED PROGRAM CONSOLIDATED F <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 408. <br /> (Check one 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) - - 3 7 3 9 <br /> BUSINESS NAME(Same as FACB WNANTm DBA-Deng Buaineee As) ; <br /> Tower Mart#886 <br /> BUSINESS SITE ADDRESS 103. CITY 104. <br /> 1434 W. Yosemite Ave Manteca, CA <br /> FACILITY TYPE FA 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 401" Is the facility located on Indian Reservation or 405. <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑Yes ❑No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 408, <br /> Tower Energy Group 310 538-8000 <br /> MAILING ADDRESS 409 <br /> 1983 W. 190th St. Suite 100 <br /> CITY 410. 1 STATE 411. ZIP CODE 411 <br /> Torrance CA 90504 <br /> M. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME a28-1. PHONE 428-2 <br /> Tower Energy Group (310) 538-8000 <br /> MAILING ADDRESS 428-3 <br /> 1983 W. 190th St. Suite 100 <br /> CITY 42%4 STATE 428-6 ZIB CODE 428-6 <br /> Torrance CA 190504 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> Tower EneMy Group (310) 538-8000 <br /> MAILING ADDRESS 416. <br /> 1983 W. 190th St. Suite 100 <br /> CITY 4v. STATE 418. ZIP CODE 419. <br /> Torrance CA 90504 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY a20, <br /> ❑ 7.FEDERAL AGENCY JK8.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,if there are questions. 421. <br /> VI.PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: <br /> I AGILITY OWNER E] 4.TANK OPERATOR 423 <br /> ❑YANK OWNER ❑ 5.FACILITY OPERATOR <br /> 406. <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that the information provided herein is true accurate,and in full compliance with legal requirements. <br /> APP [ SI NA DATE 424. 1 PHONE 425. <br /> 3/3/08 916 285-7402 <br /> APPLICANT N (Print) 426. APPLICANT TITLE 427 <br /> Paul Chevalier Maintenance Manager <br /> UPCF UST-A Rev.(122007) <br />