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't�67FROM FAX NO. n. 14 2011 04:10PM PG ?I <br /> UNIFIEO PROG"�j=OWSOUIDATED]PORM <br /> UNOERGROUND STORAGE TANK <br /> OpERATMG PERMT APPLICATION-FACELXI7Y MFORMATION <br /> (One form per fwllhy) 4W. <br /> TYPE OF ACTION El 1.NEW PERMIT 5.CHANGE OF INFORMATION 7.PERIAANENT FACILITY CLOSURE <br /> tt7mwk am zt�Indy) 3.RENEWAL PlIRMT 0 6.TEMPORARY FACILITY CLOSUR16 9,TRANSFER PURmrr <br /> -17f"M, <br /> N <br /> .. ....... .... <br /> TOTAI..NUMBiSR.()f us,rs xr FAClUTY FAciary ID 4 <br /> Li ri <br /> 3 <br /> FIUSINFM NAME(Simw ac Facifi&Naw or DBA-Doing Bmgi--,W <br /> SB Gas and Market <br /> BUSINFM SITE ADDRESS 103. Crty <br /> 615 W I Ith St Tracy <br /> FACILITY TYPE 1.MOTOR VEHICLE FUELING 112,FUHL 131STRlBUTION 403. is the fbeffity located an Indian Re.wvabm or 40& <br /> Trim In"?0 1,Yes 0 2-No <br /> 3.FARM 4.MMSSOR r,=R <br /> MR, <br /> 21 <br /> PR01PRRTy OWNER NAME PHONE <br /> Sanjay Birla (209,A34-8838 409. <br /> MAILING ADDRESS <br /> 515 W I Ith St 410. STATE 411. 2V CODE 411 <br /> CITY <br /> Traw CA 9537.6 <br /> N MN <br /> " <br /> WE Iffis"alk"721 <br /> PITONE <br /> TANK OPERATOR NAME <br /> Sanjay Birla (209)834-8838 4293, <br /> MARJNG ADDRESS <br /> 5 15 W I I th St 43". STATE Z"- 42" <br /> CITY ZIP CODE <br /> racy CA 95376 <br /> a <br /> MW, <br /> QZ 414. PRONS <br /> OWNEft NAME 41,% <br /> Sapjay Birla (209)834-8838 416. <br /> MAILING ADDRESS <br /> 515 W 1 Ith St STATE 419, 7.1pCODU <br /> CITY 41 419. <br /> Traw CA 95376 <br /> OWNERTYPB: 0 4.LOCAL AGENCYAXSTRICT 11 5,couNTY AGENCY 6.ST9M AGENCY 420, <br /> 7.FEDERAL AGENCY 0 2.NON-C3OVMU*AENT <br /> -,M <br /> an ft.Stm Board of Pqualizaliom Fuel Tax Divsmxk,ifftre an queviow. 421. <br /> V* <br /> -4 <br /> , ,-:.0"MW <br /> Ism pwmit and smd lqxl nodfmdons and mailinp tw 1.FACILITY OWNER 4.TANK OPERATOR <br /> 0 3.�FANK OWNER 5.FACILITY OPERATOR <br /> ,SUFM V I S 0 R OF DM Sl ON,§E-C-7-ION,OR OFFIC E(ReqWred ffir PUbj le Amenries On 1y) now--ft 406 <br /> Uff <br /> IN <br /> C=Tffj I S!M that the isfornnflop Proyided be"rein is me,SmEmbled in full C�p Sol requirementL <br /> APPLICANT SIGNATURB DAI @mum wfth le 14f 47J. <br /> 4m APPLICAINT 11TEE 47,7 <br /> [TF�CA_NT NAME(print)g ry, <br />