Laserfiche WebLink
qqq% (a #1A'tJf', <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION El1.NEW PERMIT ® 5.CHANGE OF INFORMATION El7.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 q <br /> 3 (Agency Use Only) <br /> 3. <br /> BUSINESS NAME(same uFACILITY NAME or DBA-Doing Business As) <br /> Arco Manteca <br /> BUSINESS SITE ADDRESS 103. CITY 104. <br /> 1711 E. Yosemite Ave Manteca <br /> FACILITY TYPE ® 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION -001 Is the facility located on Indian Reservation or 405. <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑Yes ®No <br /> II PROPERTY OWNER'INk'ORMATION ; <br /> PROPERTY OWNER NAME 407. PHONE 409. <br /> Junction Petroleum Inc. 209-823-4715 <br /> MAILING ADDRESS 409. <br /> 1711 E. Yosemite Ave <br /> CITY 410. STATE 411. ZIP CODE 412. <br /> Manteca CA 95336 <br /> , III TANKOPERATORINFORMATION . <br /> TANK OPERATOR NAME 4ze-I. PHONE 429-2 <br /> Junction Petroleum Inc. - Gurdeep Singh 209-823-4715 <br /> MAILING ADDRESS axe 3 <br /> 1711 E. Yosemite Ave <br /> CITY 4294 STATE 428-5 ZIP CODE 429-6 <br /> Manteca CA 95336 <br /> 1 .f. <br /> IV. TANK'OWNER'INFORiVIATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> Junction Petroleum Inc. 209-823-4715 <br /> MAILING ADDRESS 416. <br /> 1711 E. Yosemite Ave <br /> CITY 417. 1 STATE 419. ZIP CODE 4M <br /> Manteca CA 95336 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY ® &NON-GOVERNMENT <br /> V.'BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 0 4 8 0 4 1 Call the State Board of Equalization,Fuel Tax Division,if there are questions. 4x1' <br /> PERMIT HOLAER INFORMATION <br /> 423 <br /> Issue permit and send legal notifications and mailings to: ® I.FACILITY OWNER ❑ 4.TANK OPERATOR <br /> ❑ 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 re uiremeuts, <br /> ApPLICA SIGNATURE DATE 424. PHONE 415• <br /> �/(' 1 � 4 - S 2° 11 209-823-4715 <br /> APPLICANT NAME(print) 416. APPLICANT TITLE 4x7 <br /> u-- <br /> Gurdeep Singh President <br /> UPCF UST-A Rev.(12/2007) <br /> F <br />