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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUNDSTORAGETANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION ® E NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400' <br /> (Check one item only) ❑ 3.RENEWAL PERMIT <br /> ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY °04' FACILITY m N 1' <br /> 1 (Agency Use Only) <br /> BUSINESS NAME(Same u FACU=NAha:or DBA-Doing Business As) 3, <br /> j!Fml=Y LURE #598 <br /> BUSINESS SITE ADDRESS 103. CITY 104, <br /> 1130 N. MAIN ST. MANTECA <br /> FACILITY TYPE [II.MOTOR VEHICLE FUELING E-12.FUEL DISTRIBUTION 403. Is the facility located on Indian Reservation or 40s. <br /> ❑ 3.FARM ❑ 4.PROCESSOR ® 6.OTHER Trust lands? ❑Yes ®No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407, PHONE 408. <br /> DON FOWLER 916 375 1155 <br /> MAILING ADDRESS 409, <br /> 1471 SHORE ST. <br /> CITY 410. STATE 411, ZLPCODE 412, <br /> WEST SACRAMENTO CA 95691 <br /> IIL TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428.1. PHONE 428.2 <br /> JIFFY LUBE #598 (209 )239 0665 <br /> MAILING ADDRESS 428-3 <br /> 1130 N. MAIN ST. <br /> CITY 4294 1 STATE 428-5 ZIP CODE 428.6 <br /> MANTECA CA. 95336 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME su. PHONE 415. <br /> DON FOWLER (916 )375 1155 <br /> MAILING ADDRESS 416. <br /> 1471 SHORE ST. <br /> CITY 4M 1 STATE 419. ZIP CODE 419. <br /> WEST SACRAMENTO CA. 95691 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY M 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- Call the State Board of Equalization,Fuel Tar Division,if there are questions. 421. <br /> VI.PERMIT HOLDER INFORMATION <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(Required For Public Agencies Only) 406_ <br /> VIL APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that the information provided herein is true accurates and in full compliance with legal requirements-. <br /> APPLICANT SIGNATURE,-� DATE^ aza. PHONE�NN�(LK' Ui 425 <br /> APPLICANTNAME( C•!" 2-49!cj7 <br /> 427 <br /> ce . <br /> Z <br /> UPCF UST-A Rev.(12/2007) <br />