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FIED PROGRAM CONSOLIDATED FOR N <br /> UNDERGROUND STORAGE TANK "l <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION I0/(tl <br /> (On forth per facility) <br /> TYPE OF ACTION ® 1.NEW PERMIT ❑ 5.CHANGE OF INFORMATION <br /> (Check one item only) ❑ 7.PERMANENT FACILITY CLOSURE 40 <br /> ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF UST11 AT FACILITY 404. <br /> 1 FACILITY ID g _ 1 <br /> BUSINESS NAME s°n,e as rncu.lry N 1o.DBA- Ren Use Onl) <br /> ( Doing Bminess As) <br /> Wal eens 3 <br /> BUSINESS SITE ADDRESS <br /> Northeast corner of Farmin on Rd and E Mari osa Rd 103 CITY 104 <br /> FACILITY TYPE Stockton <br /> ® 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 003' Is the facility located on Indian Reservation or 405. <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑Yes ®No <br /> U. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME <br /> Walgreens 40]' PHONE 408 <br /> MAILING ADDRESS (650 689-5073 <br /> 151 E. 3rd Avenue 409. <br /> CITY 410. <br /> San Mateo STATE 411. ZIP CODE 412 <br /> CA 94401 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME <br /> 428-1. PHONE <br /> Same As Above Oza-z <br /> MAILING ADDRESS <br /> 42&3 <br /> CITY <br /> 428-4 STATE 428-1 <br /> ZIP CODE 428-6 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME <br /> Same As Above 414 PHONE 415 <br /> MAILING ADDRESS <br /> 416. <br /> CITY <br /> 4n_ STATE 418. ZIP CODE <br /> 419 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY <br /> ❑ 7.FEDERAL AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 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 Tax Division,if there are questions. <br /> 421. <br /> VI.PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: ® 1.FACILITY OWNER 423 <br /> ❑ 4.TANK OPERATOR <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) <br /> 906. <br /> VII.APPLICANT SIGNATURE <br /> TI CATI N: I certif that t mation rovided herein is true,accurate and in full com Hance with le al re uirements. <br /> APPLI <br /> DATE 424. PHONE 42s. <br /> APPLICA NAME(print) 10/20/2011 HO 434-9200 <br /> Frank R. Poss 426 APPLICANT TITLE <br /> 420 <br /> De artment Mana er <br /> UPCF UST-A Rev.(122007) <br />