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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK C",r <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION 0 <br /> (One form per facility) <br /> TYPE OF ACTION ❑ 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 /> 1 �L: <br /> 3 (Agency Use only) - - 'Ij <br /> BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) <br /> Marigold Shell <br /> BUSINESS SITE ADDRESS 103. CITY 104 <br /> 6131 Pacific Avenue Stockton <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 Z 2.No <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 408 <br /> Hung Tran & Mary Nguyen 209 952-4862 <br /> MAILING ADDRESS 409 <br /> 6131 Pacific Avenue <br /> CITY 410. 1 STATE 411, ZIP CODE 412 <br /> Stockton CA 95207 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. PHONE 428-2 <br /> Hung Tran (209) 952-4862 <br /> MAILING ADDRESS 428-3. <br /> 6131 Pacific Avenue <br /> CITY 4.28-4 7 STATE 428-5 ZIP CODE 428-6 <br /> Stockton CA 95207 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 41a. PHONE 415 <br /> Hung Tran (209) 952-4862 <br /> MAILING ADDRESS 416 <br /> 6131 Pacific Avenue <br /> CITY 417. 1 STATE 418. ZIP CODE 419 <br /> Stockton CA 95207 <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- 101413188161Call 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 El4.TANK OPERATOR 423 <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPE <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required for Public Agencies Only) aoe <br /> VII. APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that the information provided herein is true,accurate,and in full com liancewith legal requirements. <br /> APPLICANT SIGNATURE DATE 424. PHONE 425 <br /> 8/24/2009 209) 952-4862 <br /> APPLICANT NAME(print) 426. APPLICANT TITLE 427 <br /> Hung Thanh Tran Owner/O erato <br /> UPCF UST-A Rev.(12/2007)-1/2 www.unidoes.org <br /> a <br />