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�Olu <br /> o/ <br /> tog <br /> UNIFIED PROGRAM CONSOLIDATED FORM ►l Q� <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION ❑ 1.NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400, <br /> (Check one item only) 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 40L FACILITY ID# _ _ <br /> 1. <br /> I (Agency Use Only) 1 <br /> BUSINESS NAME(sanr u FACILITY N"Em DBA-Dom,&wines As) s. <br /> BUSINESS SITE ADDRESS ta CITY to <br /> 40;5 E Main St Stockton <br /> FACILITY TYPE W 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 401 Is the facility located on Indian Reservation or 405' <br /> El 3.FARM ❑ 4.PROCESSOR Q 6.OTHER Trust lands? ❑Yes Oj No <br /> IL PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME PHONE Ins. <br /> Jay McILrath 209 462-4685 <br /> MAILING ADDRESS qaq <br /> P.O.Box 326 <br /> CITY 410. 1 STATE 411. ZIP CODE 411 <br /> Stockton Ca. 95201 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 423-1. 1 PHONE 4z 2 <br /> Dan McILrath ( 209 ) 649-8956 <br /> MAILING ADDRESS 938-s <br /> P.O.Box 91 <br /> CITY 4284 1 STATE 428-5 ZIP CODE 42" <br /> Stockton Ca. 95201 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. 1 PHONE 41s. <br /> Jay McILrath (209 )462-4685 <br /> MAILING ADDRESS 416. <br /> P.O.Box 326 <br /> CITY 417. 1 STATE ms. ZIP CODE 41s. <br /> Stockton Ca. 95201 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 42o <br /> ❑ 7.FEDERAL AGENCY ZX&NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 1 0 2 14 6 1 21 ] 1 Call the State Board of Equalization,Fuel Tax Division,if there are questions. 4v. <br /> VI.PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: ❑ 1.FACILITY OWNER ❑ 4.TANK OPERATOR 4n- <br /> 3.TANK OWNER ❑ S.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) �a6( <br /> f' <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I certiat the information provided herein is tie,accurate,and in full com Hance with le al requirements. <br /> APPLICANT SIGNATURE DATE 10/16/2009 424. PHONE 425. <br /> 1 09 462-4685 `- <br /> APPLICANT NAME(print) 426_ APPLICANT TITLE 4n <br /> JayMcILrath Owner a <br /> UPCF UST-A Rev.(12/2007) <br /> completed <br />