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09/05/2008 18:41 9163751569 BROADBASE INC JIFFYL PAGE 02/03 <br /> qcg A41 <br /> vel <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMAT70N <br /> (one form per facility) <br /> TYPE OF ACTION I.NEW PERMIT ❑ 5.CHANGE OF INFORMATTON ❑ 7.PERMANENT FACILITY CL777 400. <br /> (CXeck one Xen1 nnty) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILTIY CLOSURE <br /> ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF TTSTs AT FACILITY °06' FACILTFY m# 3 7 'f I 1 <br /> 1 (�lgcncy U.ta Only} <br /> BUS1NF,SS NAME(same®PACI1l1Y NAW.m naA-nein Businan M) �. <br /> BUSINESS SITE ADDRRSS 103. CITY lea, <br /> 1130 N. MAIN ST. MANTECA <br /> FACILITY TYPE ❑ 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION n03. Is the facility located on Indian Reservation or 1p5 <br /> ❑ 3.FARM ❑ 4.PROCESSOR X 6.OTHER hunt lands? ❑Yes ENO <br /> IL PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME ^m� 408. <br /> DON FOWLER 916 375 1155 <br /> MAILING ADDRESS 4W <br /> 1471 SHORE ST. <br /> CITY ntn. STATE 411. 1 7_IP CODE 41Z <br /> WEST SACRAMENTO CA 95691 <br /> IIT. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME. ^=x-1 PHONE 438-2 <br /> JIFFY LUBE #598 (209 )239 0665 <br /> MAILING ADDRESS 129, <br /> 1130 N. MAIN ST. <br /> CITY nss-a STATE des s ZIP CODE Q9.6 <br /> MANTECA CA, 95336 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. 1 PHONE 415. <br /> DON FOWLER X916 ?375 1155 <br /> MAILING ADDRESS 16. <br /> 1471 SHORE.ST. <br /> CITU 417 1 STATE n's ZIP CODE 419. <br /> WEST SACRAMENTO CA. 95691 <br /> OWNER TYPE: Ij a,LOC.AT.AGENCY/DISTRICT ❑ 5,COUNTY AGENCY ❑ 6.STATE AGENCY 47a <br /> ❑ 7,FEDERAL AGENCY ® S.NON.GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 1 1 Call the Static Board of Equalization,Fuel Tax Division.if there are quesoons, 421. <br /> VI.PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and matlinp to: ❑ I.FACILITY OWNER ❑ 4.TANK OPERATOR °9 <br /> ® 3TANK OWNER 5,FACILITY OPERATOR <br /> SUPERVISOR OP DIVISION,SECTTON,OR OFFICE(Acquired For Public Agencies Only) <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: i certift that the information provided herein is true accurst and in£nll com Bance with It 1 rc uirements. <br /> APPLICAN'Y SiGNA 17A iE ^n4, PIiONIi 425. <br /> TL v 4 8 2409 1As 577 <br /> APP LICANTNAME(priM) 426. APPLIC NT � 427 <br /> EeI <br /> UPCF 1115T-A Rev.(12/7007) <br />