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LIMPED PROGRAM CONSOLIDATED FORK, ' y A <br /> UNDERGROUNDSTORAGETANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION j0ltI <br /> (Ond form per facility) <br /> TYPE OF ACTION ® L NEW PERMIT ❑ 5.CHANGE OF INFORMATION00 <br /> (Check one item only) ❑ 7.PERMANENT FACILITY CLOSURE 4 <br /> ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION 3[e% <br /> TOTAL NUMBER OF USTS AT FACILITY 404 FACILITY ID p _ _ 1. <br /> 1 A en Use Onl077 EWFL <br /> BUS(NESS NAME(samem FACILITYNA or DBA-Doing Business As) 3 <br /> Wal eens <br /> BUSINESS SITE ADDRESS 10a. CITY 1W. <br /> Northeast corner of Fa---- on Rd and E Mari osa Rd Stockton <br /> FACILITY TYPE ® L MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 40e- Is the facility located on Indian Reservation or 405. <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑Yes ®No <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 409, <br /> Walgreens (650 689-5073 <br /> MAILING ADDRESS <br /> 151 E.3rd Avenue 409 <br /> CITY 410 <br /> STATE 411. ZIP CODE 412. <br /> San Mateo CA 94401 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1 PHONE 429.2 <br /> Same As Above <br /> MAILING ADDRESS <br /> 4293 <br /> CITY <br /> 428.4 STATE 429-5 ZIP CODE 428-6 <br /> TANK OIV. TANK OWNER INFORMATION <br /> OWNER NAME <br /> 414. PHONE 415. <br /> Same As Above <br /> MAILING ADDRESS <br /> 416. <br /> CITY 41� STATE <br /> 4)8 1 ZIP CODE <br /> 419, <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY ❑ 8.NON-GOVERNMENT . <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 1Call 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: ® 1.FACILITY OWNER <br /> ❑ 4.TANK OPERATOR 425 <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) 406. <br /> VII.APPLICANT SIGNATURE <br /> TI CATI N: I cerci that t mation rovided herein is true,accurate and in full com fiance with le al re uirements. <br /> APPLI DATE 424- PHONE 425. <br /> APPucA NAME 10/20/2011 510 434-9200 <br /> (print) 426. APPLICANT TITLE <br /> Frank R.Poss 42/ <br /> De ailment Mana er <br /> UPCF UST-A Rev.(12/2007) <br />