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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facility) <br /> 400- F <br /> TYPE OF ACTION ❑ 1.NEW PERMIT ❑ 5.CHANGE OF INFORMATION El 7.PERMANENT FACILITY CLOSURE <br /> Check one item oniti) ® 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE [-] 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY aoa FACILITY ID# _ <br /> 3 (Agency Use Only) <br /> 3. <br /> BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) <br /> Nella Oil #487 dba Olympian 104 <br /> BUSINESS SITE ADDRESS 103 CITY <br /> Manteca <br /> 983 Moffat Blvd - 405. <br /> FACILITY TYPE ® 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION aoa. Is the facility located on Indian Reservation or <br /> C] 3.FARM E] 4.PROCESSOR C] 6.OTHER Trust lands? El 1.Yes ® 2.No <br /> II. PROPERTY OWNER INFORMATION <br /> 407. PHONE aos <br /> PROPERTY OWNER NAME <br /> Mel Bokides Petroleum, Inc. (209)472-3491 <br /> 409. I <br /> MAILING ADDRESS <br /> PO Box 914 <br /> 410. STATE 411- ZIP CODE Al2 <br /> CITY <br /> Lodi CA 95241 <br /> III. TANK OPERATOR INFORM428 <br /> _TIO o 1. E 4 R L. <br /> TANK OPERATOR NAME <br /> Nella Oil CompanyLLC (530) 885-0401 <br /> 42s-3, <br /> MAILING ADDRESS <br /> 2360 Lindbergh Street <br /> 42s.6 <br /> CITY 428 4. STATE 4229-5, ZiP CODE <br /> Auburn CA 95602 <br /> IV. TANK OWNER INFORMATION <br /> TANKOWNERNAME ala. PHONE 415 <br /> Mel Bokides Petroleum, Inc. (209)472-3491 <br /> 416. <br /> MAILING ADDRESS <br /> PO Box 914 <br /> 417 STATE 419. ZIP COD <br /> CITY <br /> E ate <br /> Lodi CA 95241 <br /> 420. <br /> OWNER TYPE: F-14.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY El6.STATE AGENCY <br /> ❑ 7.FEDERAL AGENCY ® 8.NON-GOVERNMENT <br /> V. BOARD OF EQ[7ALIZATION USTSTORAGE'FEE ACCOUNT NUMBER <br /> 42 <br /> TY(TK)HQ 44- 0 1 9 8 9 Call the State Board of Equalization,Fuel Tax Division,if there are questions. <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 /> a°6. <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required for Public Agencies Only) <br /> VII. APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that the information provided herein is true accurate,and in full com liance with le al re uirements. 5 <br /> CANT SIGNATURE <br /> DATE 424. PHONE ' <br /> y 8/18/2009 (530}885-0401 <br /> APPLICANT NAME(print) TL <br /> 426. APPLICANT TIE azo <br /> I <br /> Amanda AppeIt Environmental Manager <br /> UPCF UST-A Rev.(12/2007)-112 www.unidocs.org <br />