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Tkor UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION—FACILITY INFORMATION / (One tonn per facility) 3j TYPE OF ACTION ❑ I.NEW PERMIT ❑ 5.CHANGE OF INFORMATION B-7.PERMANENT FACILITY CLOSURE 4M (Check one item only) ❑ 3 RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMfI' I. FACILITY INFORMATION TOTAL NUMBER OF USTI AT FACILITY 106 FACULTfY ID# 1 A c Use On! BUSINESS NAME.(s--FACn.rrr NAME W DSA-Doingau4.A,) s W.L.Harris Tnlst BUSINESS SITE ADDRESS 103. CITY IN 16051 E.Mello Avenue Ripon FACILITY TYPE ❑ t.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 4°1' Is the facility located on Indian Reservation or 4os. ® 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑Yes ®No II, PROPERTY OWNER INFORMATION PROPERTY OWNER NAME407. PHONE nob. Lucille Harris c/o Marty Harris 209 470-7803 MAILING ADDRESS 4os. 16051 E.Mello Ave CITY 410 1 STATE 41� ZIP CODE 412. Ripon CA 95366 III. TANK OPERATOR INFORMATION TANK OPERATOR NAME 420-i. I PHONE 428-2 Same as above MAILING ADDRESS 428-3 CITY 42&4 STATE aze-s 2�CODE 4ze-s IV. TANK OWNER INFORMATION TANK OWNER NAME 414. PHONE 413. Same as above MAILING ADDRESS 416, CITY 417. 1 STATE 418. ZIP CODE 47 OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420_ ❑ 7.FEDERAL AGENCY 09 8.NON-GOVERNMENT V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY(TK)HQ 44- 1 1 Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421. VL PERMIT HOLDER INFORMATION Issue permit and send legal notifications and mailings to: ❑ 1.FACILITY OWNER ❑ 4.TANK OPERATOR 421 ® 3.TANK OWNER ❑ 5.FACILrry OPERATOR SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Requimd For Public Agencies Only) 406' VII.APPLICANT SIGNATURE CERTIFICATION: I certify that the information Drovided herein is true accurate.and in full compliance with lep]re uiremenU. APPLICANT SIGNATURE DATE yhl 2 424. PHONE 42255, APPLICANT NAME 4z4. APPLICANT ITLE T UPCF UST-A Rev.(12)2007)