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UNIFIED PROGRAi\I CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANI{ <br /> OPERATING PERMIT APPLICATION-- FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION ❑ 1.NEWPERMIT El5.CHANGE OF INFORMATION C37.PERMANENT FACILITY CLOSURE 400. <br /> (Check one item ailS) ® 3.RENEWAL PERMIT ❑ 6.TE1%4PORARY FACILITY CLOSURE ❑ 9.TRANSFER PERIMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 464' FACILITY ID# <br /> 3 (Agency Use only) <br /> BUS IN ESS NAME(Same as FacFGty fVaale or DBA-Doing Bttsnress As) 3 <br /> Flyers#487 <br /> BUSINESS SITE ADDRESS lul. CITY '04. <br /> 983 Moffat Blvd Manteca <br /> ao3305. <br /> FACILI'T'Y TYPE ® I.NIOTOR VEHICLE FUELING [1 .2.FUEL DISTRIBUTION is the facility located on Indian Reservation or <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER "frust lands? ❑ I.Yes N 2.No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNFR NANIE 407 PHONF 40S <br /> Mel Bokides Petroleum, Inc. 209 472-3491 <br /> 409. <br /> MAILING ADDRESS <br /> PO Box 914 <br /> CITY 410. STATE all. ZIP CODE 411 <br /> Lodi CA 95241 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME a2s-1. PHONE 429.2. <br /> Flyers Energy, LLC (530) 885-0401 <br /> 325-3 <br /> MAILING ADDRESS <br /> 2360 Lindbergh Street <br /> CITY 425-4. STATE 429.9. ZIP CODE 425.6. <br /> Auburn CA 95602 <br /> IV. TANK OWNER INFORMATION <br /> TANKOWNERNAME 414. PHONE 415 <br /> Mel Bokides Petroleum, Inc. (209)472-3491 <br /> 416 <br /> MAILING ADDRESS <br /> POPO Box 914 <br /> 417. S"fATE 419. ZIP CODE 419 <br /> CITY <br /> Lodi CA 195241 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL.AGENCY ® 3.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 0 4 7 4 19 8 Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421. <br /> VI. PERMIT HOLDER INFORMATION <br /> 423. <br /> Issue permit and scud legal notifications and mailings to: ❑ 1.FACILITY OWNER ® 4.TANK OPERATOR <br /> ❑ 3.TANK OWNER ❑ S.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Regulred for Public Agencies Orrl}) 4U6 <br /> VII, APPLICANT SIGNATURE <br /> CERTIFICA'riON: 1 certify that the information provided herein Is true accurate and III full c0111)IIallee j)7tll legal re uiren)ents.4�'":<''n <br /> APPI r VT SIGNA9'URF. DATE ata. PHONE 2 <br /> 10/4/2011 0530 885-0401 <br /> AP ANT NA�9E(print) 426 APPLICANT TITLE ` `a 4z7 <br /> Amanda Appelt Environmental Manager <br /> UPCF LIST-A Rev.(1212007)-1/2 WWW.unidocs.org '. <br />