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0 01 <br />UNIFIED PROGRAM CONSOLIDATED FORM <br />UNDERGROUND STORAGE TANK <br />OPERATING PERMIT APPLICATION - FACILITY INFORMATION <br />(One form per facility) <br />TYPE OF ACTION ❑ I. NEW PERMIT ❑ 5. CHANGE OF INFORMATION ❑ 7. PERMANENT FACILITY CLOSURE <br />400. <br />1Check one item only) ® 3. RENEWAL PERMIT ❑ 6. TEA4PORARY FACILITY CLOSURE ❑ 9. TRANSFER PERMIT <br />I. FACILITY INFORMATION <br />TOTAL NUMBER OF USTs AT FACILITY 404' <br />FACILITY ID li <br />F-1 <br />1 <br />1 <br />1 <br />1 <br />3 <br />(Agency Use 0,159 <br />-1 <br />-1 <br />BUSINESS NAME (Sone as FacilhtrNane or DBA - Doing Business As) <br />3 <br />Flyers #487 <br />BUSINESS SITE ADDRFSS 103. <br />CITY <br />Imo' <br />983 Moffat Blvd <br />Manteca <br />403. <br />FACILITY TYPE ® I. MOTOR VEHICLE FUELING 1712. FUEL DISTRIBUTION <br />Is the facility located on Indian Reservation or <br />Trust lands? ❑ 1. Ycs ® 2. No <br />405• <br />❑ 3. FARM ❑ 4. PROCESSOR ❑ 6. OTHER <br />II. PROPERTY OWNER INFORMATION <br />PROPERTY OWNER NAME 407 <br />PHONE <br />408. <br />Mel Bokides Petroleum, Inc. <br />1 (209).472-3491 <br />MAILING ADDRESS <br />409. <br />PO Box 914 <br />CITY 410 STATE 411 ZIP CODE <br />4t` <br />Lodi CA 95241 <br />III. TANK OPERATOR INFORMATION <br />TANK OPERATOR NAME 428-t. PHONE <br />42s•2. <br />Flyers Energy, LLC (530) 885-0401 <br />MAILING ADDRESS <br />423.3 <br />2360 Lindbergh Street <br />428.4. STATE <br />CITY <br />7CA <br />428.6. <br />Auburn 95602 <br />IV. TANK OWNER INFO <br />TANK OWNER NAME 414. 4 HO E ,r„ <br />415 <br />Mel Bokides Petroleum, Inc. (209) 472-3491 <br />MAILING ADDRESS `UL A Z01 <br />4tti <br />PO Box 914 i <br />CITY 417. STATE 418. ZIP CODE P L ° <br />4j9 <br />Lodi <br />OWNER TYPE: ❑ 4. LOCAL AGE ❑ 5. COUNTY ENCYA rATE AGENCY <br />420. <br />❑ 7. FEDERAL AGENCY &. NON•GOVFRNMEN' <br />V. Bf1OARD EQUALIIZATION UST STORAGE FEE ACCOUNT NUMBER <br />7OF <br />TY (TK) HQ 44- V 4 / 4 9 8 CA1I the Slate BO.iFd Of Equalization, Ftlet 7"AX DNISIOn, if !here are QUfSIiOnS. <br />421. <br />VI. PERMIT HOLDER INFORMATION <br />Issue permit and send legal notifications and mailings to: ❑ 1. FACILITY OWNER ® 4. TANK OPERATOR <br />423. <br />❑ 3. TANK OWNER ❑ S. FACILITY OPERATOR <br />SUPERVISOR OF DIVISION, SECTION, OR OFFICE (Required for Public Agencies 011b) <br />406 <br />VII. APPLICANT SIGNATURE <br />CERTIFICATION: I certify that the 111formation provided herein is true accurate and in full conIliattce vVill' le al re uirentents. <br />APT SIGNATURE DATE 424• P1i0NE <br />10/4!2011 530 885-0401 <br />APP17 SI <br />425. <br />AP ANT NAME (print) 426. <br />APPLICANT TITLE <br />4n <br />Amanda Appelt <br />[Environmental Manager <br />UPCF UST -A Rev. (IV2007) -112 www.unidoes.org <br />