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79 <br /> AIRUD PROGRAM CONSOLIDATED FO <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION X L NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE <br /> aoo. <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 404 1 <br /> FACILITY ID N <br /> 3 (Agency Use Only) 3. <br /> BUSINESS NAME(Same m FACnTfY NAhffi or DBA-Doing Businus As) <br /> Fast Lane Lathrop <br /> BUSINESS SITE ADDRESS 1OJ. CITY 104 <br /> 116 E. Roth Road - Lathrop <br /> FACILITY TYPE x 1.MOTOR VEHICLE FUELING F1403.2.FUEL DISTRD3UTION Is the facility located on Indian Reservation or 405. <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑Yes x No <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 408. <br /> B&G Group Inc. - Fast Lane 707-326-0369 <br /> 409. <br /> MAILING ADDRESS <br /> 111 Healdsbur Avenue <br /> CITY 410. STATE 411. ZIP CODE 412. <br /> Healdsburg CA 95448 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 4za-L PHONE 428-2 <br /> B&G Group Inc. - Fast Lane 707-326-0369 <br /> MAILING ADDRESS 428-3 <br /> 111 Healdsburg Avenue <br /> CITY 929-4 STATE 429.5 ZIP CODE 428-6 <br /> Healdsburg CA 95448 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE ms. <br /> B&G Group Inc. - Fast Lane 707-326-0369 <br /> MAILING ADDRESS 416. <br /> 111 Healdsburg Avenue <br /> CITY 417. STATE 418, ZIP CODE 419. <br /> Healdsburg CA 95448 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY ago. <br /> ❑ 7.FEDERAL AGENCY X 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- <br /> Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421. <br /> VI.PERMIT HOLDER INFORMATION <br /> 423 <br /> Issue permit and send legal notifications and mailings to: ❑ L FACILITY OWNER El4.TANK OPERATOR <br /> X 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> 406. <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that the information provided herein is true,accurate,and in full compliance with legal requirements. <br /> APPLICANT ATURE DATE 42A. PHONE 425. <br /> \a o (916) 373-1166 <br /> APPLICANT NAME(print) 426. APPLICANT TITLE 4n <br /> Dulcinea Webb Compliance Manager <br /> UPCF UST-A Rev.(12/2007) <br />