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03/02/2012 03:38 9252920074 GDF_SOLUTIONS FAX PAGE 10/15 <br /> Ak <br /> U FIED PROGRAM CONSOLIDATED FORM <br /> VNAERCROUNB STORAGE TANK <br /> OPERATING PERMIT APPLICATION—FACILITY INFORMATIONE: <br /> (One form per facility100. <br /> TYPE OF ACTION [11.NEW PERMIT ® S.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE <br /> (Check one item only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE 4.TRANSFER PERMIT <br /> I. FACII.t"Dwop-b"TION <br /> TOTAL NUMBER OF USTs AT FACILITY 4O4' FACILITY ID <br /> 2 (Ageaey Use Only) <br /> HUSMESS NAME.($WM SS IIACMTY NAMa or DSA-Do1ng Buslnew As) a. <br /> Coun#y Club 76 <br /> BUSINESS SITE ADDRESS 103. CITY 104. <br /> 2575 Counq Club Blvd. Stockton <br /> FACILITY TYPE IR I,MOTOR VEHICLE FUELING ❑ 2,FUEL DISTRMUTION 463 Is rhe facility located OA Indian Raservation or 405 <br /> ❑ 3.FARM ❑ 4_PROCESSOR ❑ 6.OTHER Trust lands? ❑Yes ®No <br /> H. PROPIRTY OWNER INFORMATION <br /> PROPIIRTY OWNER NAME 407• PHONE 405, <br /> Mike Ahmadi 925-979-0242 <br /> MAILING ADDRESS 4d9 <br /> 587 Y nacio Valley Road <br /> clTv <br /> 410 1 STATE 411. Zip CODE 412• <br /> Walnut Creek CA 94596 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME M-1 PHONE 422'2 <br /> Mike Ahmadi 209-932-1307 <br /> MAILING ADDRESS 42a.3 <br /> 2575 County Club Blvd, <br /> CITY <br /> 42S-A I STATE 429-5 ZIP CODE 42" <br /> Stockton CA 95204 <br /> IV, TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> Mike Ahmadi 1925-979-0242 <br /> MAILING ADDRESS 416. <br /> 587 Y nacio Valley Road <br /> CITY 417. STATE 41s 1 ZIP CODE 419, <br /> Walnut Creek CA 94596 <br /> OWNER TYPE: ❑ 4.LOCAL AQENCYANSTRICT ❑ 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 10, 14 S to I I Call the State Board of Equalization,Fuel Tax Division,if there are questials. 421. <br /> VL PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: 0 1.FACILITY OWNER ❑ 4.TANK OPERATOR 423 <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Publio Agencies Only) 40. <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: j4rb&that the loror ration provided herein is ae,accurate.and is fall compliance with Ie aI requirements, <br /> APPL[CffiT SIGNA DATC 424. PHONE 425. <br /> 925-979-0242 <br /> APP CANT N t) axe APPLIC T TITLE 421 <br /> Mike Ahmadi Dealer <br /> UlP'CF UST-A Rev.(1212007) <br />