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ilv�rriuvim+..... •• <br /> '1d1N3lNN081AN3 5�Lp0?� <br /> Am r,ff-lf <br /> 8lOZ ti ti AdIN <br /> UNIFIED PROGRAM CONSOLIDATED FORM ®rte qA��ryJ�� <br /> UNDERGROUND STORAGE TANK �'JJ.• <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION 1.NEW PERMIT ❑ 5.CHANGF.OF INFORMATION400. <br /> ❑ 7.PERMANENT FACILITY CLOSURE <br /> (Cheekone item only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404 FACILITY ID 4 1. <br /> 3 (Agency Use only) - - <br /> BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3_ <br /> Chevron Manteca <br /> BUSINESS SITE ADDRESS 103. CITY IDs. <br /> 1490 South Main Street Manteca <br /> FACILITY TYPE ($ 1.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? ❑ 1.Yes ❑ 2.No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 408. <br /> Gurpreet Sandhu <br /> MAILING ADDRESS 409 <br /> 2823 E. Sugarhill Terrace <br /> CITY Dublin CA 94568 410. STATE 411_ ZIP CODE 412- <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1, PHONE 428-2, <br /> Gurpreet Sandhu ( ) <br /> MAILING ADDRESS 428-3. <br /> 2823 E. Sugarhill Terrace <br /> CITY 428-4, 1 STATE 428.5. ZIP CODE 428-6- <br /> Dublin CA 94568 <br /> IV. TANK OWNER INFORMATION <br /> TANKOWNERNAME m4. PHONE 415_ <br /> Gurpreet Sandhu ( � <br /> MAILING ADDRESS 4M <br /> 2823 E. Sugarhill Terrace <br /> CITY Dublin CA 94568 417. STATE 419. ZIP CODE 419. <br /> OWNER TYPE: ❑ 4.LOCAL.AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY ($ 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 1 1 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: I2 I.FACILITY OWNER ❑ 4.TANK OPERATOR 423- <br /> 0 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,accurate and in full compBance with legal requirements. <br /> APPLICANT SIGNATURE DATE 020 PHONE 425- <br /> APPLICANT NAME(print) 426. APPLICANT TITLE 427 <br /> tTPCF UST-A Rev.(12/2007)-112 www.unidocs.org <br />