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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 ❑ 1. NEW PERMIT ® 5. CHANGE OF INFORMATION ❑ 7. PERMANENT. FACILITY CLOSURE <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 <br />3 <br />FACILITY ID # <br />(Agency Use Only) <br />_ <br />- <br />1' <br />BUSINESS NAME (Same as Facility Name or DBA - Doing Business As) 3 - <br />Gas Depot <br />BUSINESS SITE ADDRESS 103- <br />1330 Ave.E. Yosemite <br />CITY 104. <br />Manteca <br />FACILITY TYPE ® 1. MOTOR VEHICLE FUELING ❑ 2. FUEL DISTRIBUTION 403. <br />❑ 3. FARM ❑ 4. PROCESSOR ❑ 6- OTHER - <br />Is the facility located on Indian Reservation or 405. <br />Trust lands? ❑ 1. Yes ® 2. No <br />IL PROPERTY OWNER INFORMATION <br />PROPERTY OWNER NAME 407. <br />Kevin Hur <br />PHONE 408. <br />(209) 825-7722 <br />MAILING ADDRESS 409. <br />1330 E. Yosemite Ave. <br />CITY 410- <br />Manteca <br />STATE 411- <br />Ca. 195336 <br />ZIP CODE 412• <br />M. TANK OPERATOR INFORMATION' <br />TANK OPERATOR NAME 428-1• <br />Same <br />PHONE 428-2. <br />( ) <br />MAILING ADDRESS 428-3. <br />CITY 428-4- <br />STATE 428-5- <br />ZIP CODE 428-6. <br />IV. TANK OWNER INFORMATION ; <br />TANK OWNER NAME 414_ <br />Same <br />PHONE 415. <br />( ) <br />MAILING ADDRESS 416' <br />CITY 41777 <br />418, <br />ZIP CODE 419. <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- 1 014 3 3 7 5 Call the State Board of Equalization, Fuel Tax Division, if there are questions. 421. <br />VI. PERMIT HOLDER INFORMATION <br />issue permit and send legal notifications and mailings to: ® 1. FACILITY OWNER ❑ 4. TANK OPERATOR 423' <br />❑ 3. TANK OWNER ❑ 5. FACILITY OPERATOR <br />SUPERVISOR OF DIVISION, SECTION, OR OFFICE (Requitedfor Public Agencies Only) 406. <br />V11.1 APPLICANT SIGNATURE_ <br />CERTIFICATION: I certify that the information provided here-iq is true, accuratevind in fqil compliance with legal requirements. <br />APPLICANT SIGNATURE <br />Z4 11ald <br />DATE 424• <br />1(209) <br />PHONE 425. <br />825-7722 <br />APPLICANT NAME 426 <br />Kevin Hur <br />APPLICAWTTITL427 <br />Owner <br />- VIli <br />UPCF UST -A Rev. (122407) -12 www.unidoc&org <br />1 <br />r <br />