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pa70 O' 11 <br /> UNIFIED PROGRAM CONSOLIDATED FORM vs <br /> UNDERGROUNDSTORAGETANK <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 400' <br /> (Check nue Rem Wy) ❑ 3,RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TO'I'AL NUMBER OF USTs AT FACILITY 404 FACILITY ID N <br /> 2 (Agency,UseOnl)) - - 3 <br /> BUSINESS NAME(Same as Facility Name or DBA-Doing Buriness As) 3. <br /> MANTECA SHELL <br /> BUSINESS SITE ADDRESS 103. CITY 109. <br /> 824•E. YOSEMITE AVE. MANTECA, CA. 95336 <br /> FACILITY TYPE M I.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? ❑ I.Yes ® 2,No <br /> II. PROPERTY <br /> -0 <br /> 11. ; <br /> PROPERTY OWNER NAME 407. PHONE OF <br /> PETROLEUM VENTURES, LLC. 209 577-6000 <br /> MAILING ADDRESS 409' <br /> 601 Mc HENRY AVE. <br /> CITY 410. STATE 411. ZIP CODE 412 <br /> MODESTO CA 95350 <br /> III, TANK OPERATOR TNFUHIVIATION 4y <br /> TANK OPERATOR NAME 41e-1• PHONE 418$ <br /> ( ) <br /> MAILING ADDRESS 428-3' <br /> CITY 4z9+ STATF. 429-5. ZIP CODE 429-6. <br /> IV. TANK OWNER INFORMATION - <br /> TANK OWNER NAME 414. PHONE 415, <br /> PETROLEUM VENTURES, LLC. (209) 577-6000 <br /> MAILING ADDRESS 416. <br /> 601 Mc HENRY AVE. <br /> CITY 4n. 1 STATE 418. 1 ZIPCODE 419, <br /> MODESTO CA 95350 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY 19 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)IIQ 44- Cnll the Stale Board of Equalization,Fuel Tax Division,it'lhere are questions, 431. <br /> VI.PERMIT HOLDERINFORMATION <br /> Issue permit and send legal notifications and mailings to: ❑ 1.FACILITY OWNER ❑ 4.TANK OPERATOR 423, <br /> ® 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(RegnlmdJor Public Agencies Only) 406. <br /> VII. APPLICANT SIGNATURE <br /> CERTIFICATION: I e t e tnformat' n rovidad herein is true,accurate,and in full compliancep With legal requirements. <br /> APPLICANT SIGNATOR DATE 424 PHONE 425. <br /> 1/24/2011 209 577-6000 <br /> APPLICANT NAME(prin) 426• 1 APPLICANT TITLE 923 <br /> PETROLEUM VkNTURES c/o R. HENRY CUSTOMER SERVICE COORDINATOR <br /> UPCF UST-A Rev.(122007)-12 www.uitidoes.org <br />