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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION - FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION Fl 1.NEW PERMIT ® 5.CHANGE OF INFORMATION El 7.PERMANENT FACILITY CLOSURE 400 <br /> (Check one item only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404. FACILITY ID# <br /> 3 (Agency Use Only) <br /> 3' <br /> BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) <br /> Gas Depot <br /> BUSINESS SITE ADDRESS 103 CITY 104, <br /> 1330 Ave.E. Yosemite Manteca <br /> 405. <br /> FACILITY TYPE ® 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403 Is the facility located on Indian Reservation or <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑ 1.Yes ® 2.No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408. <br /> Kevin Hur (209 825-7722 <br /> MAILING ADDRESS <br /> 1330 E. Yosemite Ave. <br /> CITY 41° STATE 411. ZIP CODE z. <br /> Manteca Ca. 95336 AUG < <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. PHONE SAN.IOAk),WN COUNTY 428-2. <br /> ( ) ENVIF,, NNIENTAL. <br /> Same <br /> 428-3. <br /> MAILING ADDRESS <br /> CITY 428-4 STATE 428-5. ZIP CODE 428-6. <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. 1 PHONE 415. <br /> Same ( ) <br /> 416. <br /> MAILING ADDRESS <br /> CITY an STATE 418. ZIP CODE alp. <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- 101413131715 all 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 E] 4.TANK OPERATOR <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR''' <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Requiredfor Public Agencies Only) Y.- '406. <br /> VII. APPLICANT SIGNATURE <br /> CERTIFICATION: I certifv that the information provided here' is true,accurate nd in f I compliance with legal requirements. 1 <br /> APPLICANT SIGNATURE DATE nn 424. PHONE <br /> d� / (209) 825-7722 <br /> APPLICANT NAME426 APPLICANT TI L <br /> r <br /> Kevin Hur Owner yy <br /> Ad <br /> IIPCF LIST-A Rev.(12/2007)-1/2 w111%.unidocs.org Lij <br /> ri <br />