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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION- FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION Z 1.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 FACILITY ID# <br /> 3 (Agency Use Only) <br /> BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3, <br /> Stan Boyett & Son Inc DBA Boyett Petroleum <br /> BUSINESS SITE ADDRESS 103. CITY 104. <br /> 1137 W Lathrop Manteca <br /> FACILITY TYPE ® 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403. Is the facility located on Indian Reservation or 405. <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑ 1.Yes ® 2.No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 408. <br /> Stan Boyett & Son Inc DBA Boyett Petroleum (209) 577-6000 <br /> MAILING ADDRESS 409. <br /> 601 McHenry Ave <br /> CITY 410. 1 STATE 411. ZIP CODE 412. <br /> Modesto CA 95350 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME. 428-1. PHONE 428-2. <br /> Stan Boyett & Son Inc DBA Boyett Petroleum (209) 577-6000 <br /> MAILING MAW SS 428-3. <br /> 601 McHenry Ave <br /> CITY 428-4 STATE 428-5. ZIP CODE 428-5. <br /> Modesto CA 95350 <br /> IV. TANK OWNER INFORMATION <br /> "TANK OWNER NAME 414, PHONE 415. <br /> Stan Boyett & Son Inc DBA Boyett Petroleum (209) 577-6000 <br /> MAILING ADDRESS 415. <br /> 601 McHenry Ave <br /> CITY 417. STATE 418. ZIP CODE 419. <br /> Modesto CA 95350 <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 /> TY(TK)HQ 44- 10 12 19 10 5 1 8 1 Call 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 ❑ 4.TANK OPERATOR 423. <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required for Public Agencies Only) 405, <br /> VII. APPLICANT SIGNATURE <br /> CERTIFICATION: 1 certify that the information provided herein is true,accurate,and in full compliance with legal requirements. <br /> APP ANT SI NATURE DATE 424 1 PHONE 425. <br /> 6/29/2009 (559)444-1730 <br /> AP ICA NAME(print) 425 APPLICANT TITLE 427 <br /> LC Services Contractor <br /> UPCF UST-A Rev.(12/2007)-1/2 www.unidocs.org <br />