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RPOEIVE <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUNDSTORAGETANK NOV 15 2016 <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> TYPE OF ACTION ® 1.NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACIE{'€YM91W NT 400- <br /> (Check one item only) ❑ 3.RENEWAL PERMIT [16.TEMPORARY FACILITY CLOSURE El 9.TRANSFER PERMITUU <br /> I. FACILITY INFORMATION A a 2b7� <br /> TOTAL NUMBER OF USTs AT FACILITY 404- FACILITY ID# t. <br /> 2(20k gal, 12k/8k gal split) (Agency Use Only) <br /> BUSINESS NAME(Same vFACa.rrYNA or DBA-Doing Business As) 3. <br /> AAC,f F6/rcL Life, <br /> BUSINESS SITE ADDRESS - 103. CITY 104. <br /> 1490 SOUTH MAIN STREET MANTECA <br /> FACILITY TYPE ® 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? ❑Yes ®No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408. <br /> (ANNIE)GURPREET SANDHU 925 785-2000 <br /> MAILING ADDRESS 409. <br /> 2823 E.SUGARHILL TERRACE <br /> CITY 410. STATE 411. ZIP CODE 412. <br /> DUBLIN CA 94568 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1 PHONE 428-2 <br /> SAME AS PROPERTY OWNER ` <br /> MAILING ADDRESS J 428-3 <br /> CITY 428-1 STATE 428-5 ZIP CODE 428-6 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> SAME AS PROPERTY OWNER - <br /> MAILING ADDRESS 416. <br /> CITY 417 STATE 418. 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: ® I.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 certif the informati provided herein is true,accurate,and in full compliance with legal requirements. <br /> APPLICANT SIGNATURE DATE 424. PHONE 425, <br /> 1( r 5116 925 785-2000 <br /> APPLICANT NAME mt) _ 426- APPLICANT TITLE 427 <br /> (ANNIE)GURPREETSANDHU f rkar PEar <br /> UPCF UST-A Rev.(12/2007) <br />