Laserfiche WebLink
u_}_.. :::s -i.==r� -. ____ "'s.:s--]7 •2:�tis ..v-ii=_:.'ia:�:.:•::��.:�_c.:wc..:::_v»=:__:_.:�._:. <br /> ____________ <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> =OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION ❑ 1.NEW PERMIT ® 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE <br /> aoo. <br /> (Check one item only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ;919.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404. <br /> FACILITY ID# <br /> 3 (Agency Use Only) <br /> 3. <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) <br /> National Petroleum-Stockton <br /> 103. CITY toa. <br /> BUSINESS SITE ADDRESS <br /> 713 N.El Dorado St. Stockton <br /> 403. 405. <br /> FACILITY TYPE ® I.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION Is the facility located on Indian Reservation or <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER <br /> Trust lands? ❑Yes ®No <br /> II. PROPERTY OWNER INFORMATION <br /> 7407. -�7PROPERTY OWNER NAME HONE aos. <br /> New Era Energy,LLC. (408) 577-0202 <br /> 409. <br /> MAILING ADDRESS <br /> 405-11 Camille Circle 4tz. <br /> 410. STATE �411P CODECITY <br /> San Jose CA 134 <br /> III. TANK OPERATOR INFORMATION <br /> azs-t. PHONE 428-2 <br /> TANK OPERATOR NAME <br /> Engineer's Associates,Inc. (510) 677-4467 <br /> 428-3 <br /> MAILING ADDRESS <br /> 405 Camille Circle Suite 11 428-6 <br /> CITY 428-4 [CA <br /> TE 428-5 ZIP CODE <br /> San Jose 95134 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME ata. PHONE 415. <br /> New Era Energy,LLC. (408) 577-0202 <br /> 416. <br /> MAILING ADDRESS <br /> 405-11 Camille Circle <br /> CITY ate. STATE��418 �95IC304 <br /> 419San Jose CA <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY [1 6.STATE AGENCY azo. <br /> ❑ 7.FEDERAL AGENCY ® 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 0 1 4 1 7 8 3 7 Call the State Board of Equalization,Fuel Tax Division,if there are questions. <br /> alt. <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 certifythat the information provided herein is true,accurate,and in full compliance with le al re uirements. azs. <br /> APPLICANT SIGNATURE DATE RPHONE <br /> 3/20/2014 <br /> APPLICANT NAME(print) <br /> 426. APPLICANT TITLE azo <br /> Nick Patel Mana er <br /> MAS 2 0 2014 <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> UPCF UST-A Rev.(12/2007) <br />