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1 ✓ <br /> UNIFIED PROGRAM CONSOLIDATED FORM s0 16 un <br /> UNDERGROUND STORAGE TANK 61131016- >CX <br /> • OPERATING PERMIT APPLICATION-FACILITY INFO ATION <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 <br /> ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 4°4. FACILITY ID# 1 <br /> TWO (Agency Use Only) F I A - 0 1 0 1 0 - 1 9 1 0 9 <br /> BUSINESS NAME(Same m FACILITY NAME or DBA-Doing Business As) 3. <br /> COUNTRY CLUB FOOD & FUEL <br /> BUSINESS SITE ADDRESS 103. CITY 104. <br /> 1856 W. COUNTRY CLUB BLVD 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? ❑Yes ®No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 408. <br /> FASSEL ELDER 209 239-4347 <br /> MAILING ADDRESS 409. <br /> 4880 Peach Ave <br /> CITY 410. 1 STATE 411. ZIP CODE 412. <br /> MANTECA CA 95337 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. PHONE 428-2 <br /> FASSEL ELDER 209 239-4347 <br /> MAILING ADDRESS 428-3 <br /> 4880 Peach Ave <br /> CITY 42F7 STATE 428-5 ZIP CODE 428-6 <br /> MANTECA CA 95337 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> FASSEL ELDER ( 209 239-4347 <br /> MAILING ADDRESS 416. <br /> 4880 Peach Ave <br /> CITY 417. 1 STATE 418. ZIP CODE 419. <br /> MANTECA CA 95337 <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- 1 1 Call 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 ❑ 4.TANK OPERATOR 423 <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 t informati vided herein is true,accurate,and in full compliance with legal requirements. <br /> APPLICANT SIGNATURE DATE Q 424. PHONE 425. <br /> 03,08-0 209 239-4347 <br /> APPLICANT NAME(print) 426. APPLICANT TITLE 427 <br /> • FASSEL ELDER OWNER <br /> UPCF UST-A Rev.(12/2007) <br />