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0 6 <br /> UNIFIED 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 ❑ S.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 40a' <br /> (Check one liens only) ❑ 3,RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 401' FACILITY ID 11 <br /> 2 (Agency Use on <br /> BUSINESS NAME(Same as Facll/tyNa a o',tr`DfBA-Doing Busine'sslAls/) rn ] 3 <br /> VIrV I.W1 -W" <br /> O <br /> BUSINESS SITE ADDRESS 103. CITY 104. <br /> 824 E. YOSEMITE AVE. MANTECA, CA. 95336 <br /> FACILITY TYPE ® 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403' Is the facility located on Indian Reservation or 45s. <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑ L Yes ® 2.No <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 408. <br /> PETROLEUM VENTURES, LLC. 209 577-6000 <br /> MAILING ADDRESS 400. <br /> 601 Mc HENRY AVE. <br /> CITY 410, 1 STATE 411. ZIP CODE 412. <br /> MODESTO CA 95350 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. 1 PHONE 428.2. <br /> SUZAN & PIERRE CHAHOUD (209) 345-1689 <br /> MAILING ADDRESS 428. <br /> 824 E. YOSEMITE AVE. <br /> CITY 423.4. STATE 428-S 1 ZIP CODE 428.6. <br /> MANTECA CA 95336 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414, PHONE 415. <br /> PETROLEUM VENTURES, LLC (209) 577-6000 <br /> MAILING ADDRESS 46. <br /> 601 Mc HENRY AVE. <br /> CITY 417. 1 STATE 418. ZIPCODE 419. <br /> MODESTO CA 95350 <br /> OWNER TYPE: ❑ 4,LOCAL AGENCYIDISTRICT ❑ S.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY ® S.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TIC)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: ❑ I.FACILITY OWNER 0 4.TANK OPERATOR 421' <br /> ® 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Requlrecifor Public Agencies Only) 406, <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I certifyA-ba-6thelinformation Drovided herein is true accurate and in full compliance with legal requirements. <br /> APPLICANT SIGNATURE DATE 424. PHONE 425. <br /> 3/10/2011 209 577-6000 <br /> APPLICANT NAME(print) 426. APPLICANT TITLE 427 <br /> PETROLEUM VEN RES c/o R. HENRY CUSTOMER SERVICE COORDINATOR <br /> UPCF UST-A Rev.(12/2007).ItZ www.unidocs.urg <br />