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`,NIFIED PROGRAM CONSOLIDATED FOh.eC <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION(one form per faetiry) <br /> 19 WOO <br /> TYPE OF ACTION E] 1.NEW PERMIT 5.CHANGE OF INFORMATION ® 7.PERMANENT FACILITY CLOSURE <br /> (Check one item only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> 1. <br /> TOTAL NUMBER OF USTs AT FACILITY 4N, FACILITY ID N - 7nor <br /> 1 A Use Onl 3. <br /> BUS WESSNAME(S9mee4FACn.3ry NAM DBA-Dai�Bminns M) N ✓AH r� P <br /> Levand Bright FamilyTrust Properry , (�N '` mTV <br /> 0" <br /> BUSINESS SITE ADDRESS <br /> 3 East Eleventh Street 4os. <br /> FACILITY TYPE ❑ L MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION Is the 40 <br /> ❑ 3.FARM ❑ 4.PROCESSOR ® 6.OTHER <br /> H. PROPERTY OWNER INFORMATION <br /> . <br /> PROPERTY OWNER NAME 4e/ PHONE 40s. <br /> Louis Levand Trust,Et.al. 661 904-2133 <br /> 409. <br /> MAILING ADDRESS <br /> 24692 Sand Wedge Lane Ott ZIP CODE 412 <br /> 410. STATE <br /> CITY <br /> Valencia CA 91355 <br /> M. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-L PHONE 429-2 <br /> Unknown ( ) 428-3 <br /> MAILING ADDRESS <br /> CITY4294 STATE 428-5 ZIP CODE 429-6 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME a4. PHONE 415. <br /> Louis Levand Trust,Et. al. (661) 904-2133 <br /> 416. <br /> MAILING ADDRESS <br /> 24692 Sand Wedge Lane <br /> CITY 4STATE 419. ZIP CODE °10. <br /> n. <br /> Valencia CA 91355 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY ® 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> 431. <br /> TY(TK)HQ 44- Call the State Board of Equalization,Fuel Tax Division,if there are questions. <br /> VI.PERMIT HOLDER INFORMATION <br /> 423 <br /> Issue permit and send legal notifications and mailings to: ❑ 1.FACILITY OWNER ❑ 4.TANK OPERATOR <br /> ❑ 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 com Hance with legal requirements. azs. <br /> APPLICANT SII6PF,NUPE DATE °24- PHONE <br /> 02/03/2014 209) 467-1006 <br /> APPLICANT NAME(print) 426- APPLICANT TITLE 4n <br /> William Little A en for Levand FamilTrust <br /> UPCF UST-A Rev.(12/2007) <br />