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UNIFIED PROGRAM CONSOLIDATED FORAM <br /> UNDERGROUND S'T'ORAGE TANK <br /> OPERATING PER1%,HT APPLICATION-FACILITY INFOR`rIATION <br /> (One form per facility) <br /> EOFN C11.NEW PERMIT ® S.CHANGE OF INFORMATION [17.PERMANENT FACILI'T'Y CLOSURE <br /> 400. <br /> (Check one item only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ ().TRANSFER PERMIT <br /> I. FACILITY INFORMATION -'�-A 000,2 6tV ViZD 1'W765_ <br /> TOTAL_NUMBER OF USTs A'I'EAGLET"1'Y 404' FACILITY ID# _ <br /> 3 (Agency Use Onl}) <br /> J <br /> BUSINESS NAME(Sana sFACILITYNAMEorDOA-DoingBusinessAs) <br /> FLYERS #427 104 <br /> BUSINESS SITE ADDRESS 301 CITY <br /> 3300 WATERLOO ROAD STOCKTON <br /> 403. dQ5 <br /> FACILITY'TYPE ® 1.MOTOR VEHICLE FUELING [12.FUEL DISTRIBUTION Is the facility located on Indian Reservation or <br /> ❑ 3.FARNi ❑ 4.PROCESSOR ❑ 6.OTHER <br /> Trustlands? ❑Yes ®INTO <br /> II. PROPERTY OWNER INFORMATION <br /> 407. r(530) <br /> NE 408 <br /> PROPERTY OWNER NAME <br /> r.1PI A+ 0P9 P-�LLCS 885-0401 <br /> 409. <br /> MAILING ADDRESS <br /> 2360 LINDBERGH STREET 412 <br /> CITY <br /> 410. STATE 411 ZIP CODE <br /> AUBURN CA 956Q2 <br /> III. TANK OPERATOR INFORMATION <br /> 4zs-z <br /> TANK OPERATOR NAME428-1. PHONE <br /> FLYERS ENERGY LLC (530) 885-0401 <br /> 4zs•3 <br /> MAILING ADDRESS <br /> 2360 LINDBERGH STREET 42s-s ZIP CODE 42s-6 <br /> CITY 428.4 STATE <br /> AUBURN CA 95602 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PRONE 415 <br /> FLYERS ENERGY LLC (530) 8$5-04Q1 <br /> 416. <br /> MAILING ADDRESS <br /> 2360 LINDBERGH STREET <br /> CITY 417. STATE 418. ZIP CODE 419. <br /> AUBURN CA 95602 <br /> OWNERTYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ <br /> 6.STATE AGENCY 4'0 <br /> ❑ 7.FEDERAL AGENCY (Q 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(M)HQ 44- 0 1 9 8 9 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 send legal notifications and mailings to: ❑ 1.FACILITY OWNER C14.TANKOPERATOR <br /> ® 3.'TANK OWNER ❑ 5.FACILITY OPERATOR <br /> sob. <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Acquired For Public Agencies Only) <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that the informatlou 1wovided Ilet•ehti is true accurate,and h3 full cont)Hance with 10 al re 'ements. <br /> Ll-'ANT SiGNr\"TUBE DATE 424. PHONE a R` - 425 <br /> 5/18/20121 (530NM0401 <br /> A l_!CA T NAr (print) 426. APPLICANT TITLE M 427 <br /> AMANDA APPELT ENVIRONMENTAL MANA R;-�` <br /> FF. <br /> UPC!'UST-A Rev.(12/2007) J_ <br />