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uM IED PROGRAM CONSOLIDATED FORivt /old l01 a <br /> UNDERGROUND STORAGE TANK <br /> L�OPERA'T'ING PERMIT APPLICATION- FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION ® 1.NEW PERMIT ❑ 5.CHANGE CIE INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400 <br /> (Cheek one item only) ❑ 3.RENEWAL PERMIT Q 6.TEMPORARY FACILITY CLOSURE <br /> ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF UST5 AT FACILITY 404' FACILITY ID# _ <br /> 3 (Agency Use Only) TT7L 7 <br /> BUSINESS NAME(Same as l:acillly Name or DBA-Doing Business As) ; <br /> CV It W.-M-rFC A -t 29 <br /> BUSINESS SITE ADDRESS 103. CITY 104 <br /> 1137 W Lathro Manteca <br /> FACILITY TYPE ® l.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403. is the f ility located on Indian Reservation or 405. <br /> ❑ 3.FARM ❑ 4.PROCESSOR 6,OTHER Trust lands? ❑ 1.Yes Z 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 /> MA L NG ADDRESS <br /> 409. <br /> 601 McHen Ave <br /> CITY 410. STATE 411. <br /> ZIP CODE 412. <br /> Modesto CA 195350 r <br /> IIx. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 62$-1. PHONE 428-2. <br /> Stan Bo eft& Son Inc DBA Bo eft Petroleum 1 (209) 577-6000 <br /> MAILING ADDRESS 4za <br /> 601 Mol-len Ave <br /> CITY 428-4, STATE 42&5. ZIP CODE 4:3-6, <br /> Modesto I-CA 95350 <br /> IV. TANTO OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> Stan Bo eft & Son Inc DBA Bo ett Petroleum (209) 577-6000 <br /> MAILING ADDRESS 416 <br /> 601 McHenry Ave _ <br /> CITY 417. 1 STATE 418, ZIP CODE <br /> Modesto CA 95350 <br /> OWNER TYPE, ❑ 4.LOCAL AGENCYIDISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY 0 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 10 12 9 Q 5 8 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: ® L FACILITY OWNER ❑ 4.TANK OPERATOR 423, <br /> ❑ 3.TANK OWNER 0 5.FACILITY OPBRATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(RequlredforPuhlicAgencies Only) aos <br /> VII. APPLICANT SIGNATURE <br /> CERTIFICATION: I eertify thatthe information provided herein is true accurate and in t1Lll compliance with legal re uirftents.' <br /> APPI ANT Sl NATURE DATE 424. PHONE 4zs. <br /> 6/29/2009 559 444-1740 <br /> AP IC AME(print) 4�• APPLICANT TITLE 427 <br /> LC Services Contractor <br /> UPCIF UST-A Rev.(12/2007)-1/2 www.unidoes.org <br /> �,w <br />