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C e d1 . ,1 #487, Not Yet Submitted <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION ❑ 1.NEW PERMIT El 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400. <br /> (Check one item only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> L FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404. FACILITY ID# <br /> 3 (Agency Use Only) <br /> BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3. <br /> FLYERS#487 <br /> BUSINESS SITE ADDRESS 103. CITY 104. <br /> 983 Moffat Blvd Manteca <br /> FACILITY TYPE 0 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? ❑ 1.Yes [j] 2.No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 40a <br /> Mel Bokides Petroleum, Inc. 209-472-3491 <br /> MAILING ADDRESS 404 <br /> PO Box 914 <br /> CITY 410. STATE 411. ZIP CODE 411 <br /> Lodi CA 95241 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. PHONE 428-2. <br /> Flyers Energy LLC 530-885-0401 <br /> MAILING ADDRESS 428-3. <br /> 2360 Lindbergh St. <br /> CITY 428-4. STATE 428-5. A <br /> CODE 428-6,. <br /> Auburn CA 602 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414, PHONE 415, <br /> Mel Bokides Petroleum, Inc. 209-472-3491 <br /> MAILING ADDRESS 416, <br /> PO Box 914 <br /> CITY 417. STATE 418. ZIP CODE 419. <br /> Lodi CA 95241 <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- 10 4 7 4 9 8 1 Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421. <br /> VI.PERMIT HOLDER INFORMATION <br /> - <br /> Issue permit and send legal notifications and mailings to: ❑ 1.FACILITY OWNER El 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 the information provided herein is true accurate,and in full compliance with legal requirements. <br /> A ANT SIGNATURE DATE 424- PHONE 425. <br /> 2011/10/04 530-885-0401 <br /> PLICANT NAME(print) 426. APPLICANT TITLE 427 <br /> Amanda Appelt Environmenta Manager <br /> UPCF UST-A Rev.(12/2007)-1/2 www.unidoes.org <br /> Click Pore to unlock PDFKit.NET <br />