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FE�?3% z-1-:,"99 <br />Wn <br />UNIFIED PROGRAM CONSOLIDATED FORM <br />UNDERGROUND STORAGE TANK <br />OPERATING PERMIT APPLICATION - FACILITY INFORMATION <br />(One form per facility) <br />TYPE OF ACTION ❑ I. NEW PERMIT ❑ 5. CHANGE OF INFORMATION ® 7. PERMANENT FACILITY CLOSURE 400. <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- <br />FACILITY ID H <br />I <br />(Agency Use Only) <br />BUSINESS NAME (Same as FACILITY NAME or DBA- Doing Business As) <br />Levand Family Trust Property <br />BUSINESS SITE ADDRESS 103. <br />CRY 104. <br />47 East Eleventh Street <br />Tracy <br />FACILITY TYPE ❑ I. MOTOR VEHICLE FUELING ❑ 2. FUEL DISTRIBUTION 403. <br />Is the facility located on Indian Reservation or 405. <br />❑ 3. FARM ❑ 4. PROCESSOR ® 6. OTHER <br />Trust lands? ❑ Yes ® No <br />II. PROPERTY OWNER INFORMATION <br />PROPERTY OWNER NAME 407. <br />PHONE 408. <br />Levand Family Trust <br />(661) 904-2133 <br />MAILING ADDRESS 409, <br />24692 Sand Wedge Lane <br />CITY 410- <br />STATE 411- <br />ZIP CODE 412. <br />Valencia <br />CA <br />91355 <br />M. TANK OPERATOR INFORMATION <br />TANK OPERATOR NAME 428-1. <br />PHONE 428-2 <br />Unknown <br />( ) <br />MAILING ADDRESS 428-3 <br />CITY 4294 <br />STATE 428-5 <br />ZIP CODE 428-6 <br />N. TANK OWNER INFORMATION <br />TANK OWNER NAME 414. <br />PHONE 415. <br />Levand Family Trust <br />(661) 904-2133 <br />MAILING ADDRESS 416. <br />24692 Sand Wedge Lane <br />CITY 412 <br />STATE 418. <br />ZIP CODE 419. <br />Valencia <br />CA <br />91355 <br />OWNER TYPE: ❑ 4. LOCAL AGENCYIDISTRICT ❑ 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 />TY (TK) HQ 44- 1 1Call the State Board of Equalization, Fuel Tax Division, if there are questions. 4'"1 <br />VI. PERMIT HOLDER INFORMATION <br />Issue permit and send legal notifications and mailings to: ❑ 1. FACILITY OWNER ❑ 4. TANK OPERATOR 423 <br />Q, 3. TANK OWNER ❑ 5. FACILITY OPERATOR <br />SUPERVISOR OF DIVISION. SECTION. OR OFFICE (Required For Public Agencies Only) 406. <br />VII. APPLICANT SIGNATURE <br />CERTIFICATION: I certify that the information provided herein is true, accurate, and in full compliance with legal requirements. <br />APPLIC TSI A7 <br />DATE 474 <br />PHONE 9n. <br />9/20/2013 <br />(209) 467-1006 <br />APP I ANT IVAME (print) 426. <br />U <br />APPLICANT TITLE 427, <br />Robert Marty <br />Agent for Levand Family Trust <br />2UK- <br />UPCIF UST -A Rev. (122007) e:, -t 281 I <br />