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RECEIVED <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK SAN JUAUUIN COUNTY <br /> OPERATING PERMIT APPLICATION- FACILITY INFO ANIMNCY SERVICE <br /> (One form per facility) <br /> TYPE OF ACTION ® I.NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400' <br /> (Check owe nem,,,,1y) ❑ g RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404- FACILITY ID# �- <br /> 3 (Agency Use Only) -10 � 1 7 8 1 9 <br /> BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3. <br /> GASSPECS, INC. dba GREAT AMERICAN GAS & CAR WASH <br /> BUSINESS SITE ADDRESS 101- CITY 104. <br /> 2115 W. Yosemite Ave. Manteca <br /> FACILITY TYPE ® L MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403. Is the facility located on Indian Reservation or 001 <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑ 1.Yes ® 2.No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 400- PHONE 409. <br /> GASSPECS, INC. 209 823-5654 <br /> MAILING ADDRESS 409. <br /> 1883 ROCHESTER <br /> CITY 410. STATE 411, ZIPCODE 412. <br /> TRACY CA 95377 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. PHONE 428-2_ <br /> GASSPECS, INC. (209) 823-5654 <br /> MAILING ADDRESS 429-3. <br /> 1883 ROCHESTER <br /> CITY 428-1 STATE 428-5- ZIP CODE 42". <br /> TRACY CA 95377 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> GASSPECS, INC. (209)823-5654 <br /> MAILING ADDRESS 41C <br /> 1883 ROCHESTER <br /> CITY 417. STATE 419. ZIP CODE 419. <br /> TRACY CA 95377 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 430 <br /> ❑ 7.FEDERAL AGENCY ® 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 1Call the State Board of Equalization,Fuel Tax Division,if there are questions. 021' <br /> VI. PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: ❑ I.FACILITY OWNER ❑ 4.TANK OPERATOR 423 <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required for Public Agencies Only) 40s. <br /> VII. APPLICANT SIGNATURE <br /> CERTIFICA certi t a e ation provided herein is true accurate and in full compliance with legal requirements. <br /> APPLICANT SI%\Tn,, DATE 9 424, PHONE 425. <br /> �0 209 823-5654 <br /> APPLICANTNAM 42h. APPLICANT TITLE 427 <br /> SYED K. E VICE PRESIDENT <br /> UPCF UST-A Rev.(122007)-12 w .unidocs.org <br />