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z.. �rrr <br /> IFIED PROGRAM CONSOLIDATED FM[ <br /> UNDERGROUND STORAGE TANK Cr <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 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# _ t <br /> 3 (Agency Use Only <br /> BUSINESS NAME(same as FACILITY NAME or DBA-Doing Business As) 3. <br /> Valero Corner Store #3641 <br /> BUSINESS SITE ADDRESS 103. CITY 104. <br /> 1210 E. Hammer Lane Stockton <br /> FACILITY TYPE ® 1.MOTOR VEHICLE FUELING 403. 405. <br /> ❑ 2.FUEL DISTRIBUTION Is the facility located on Indian Reservation or <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑Yes ®No <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 408. <br /> Shadrall Hammer Lane LP (201) 930-8800 <br /> MAILING ADDRESS 409. <br /> 50 Tice Blvd., Suite 320 <br /> CITY 410. 1 STATE 411• ZIPCODE 412. <br /> Woodcliff Lake NJ 07677-7658 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. PHONE 428-2 <br /> Valero California Retail Company 559-582-0241 <br /> MAILING ADDRESS 428-3 <br /> 685 W. Third Street <br /> CITY 428-4 STATE 428-5 ZIP CODE 428-6 <br /> Hanford CA 93230 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> Valero California Retail Company 559-582-0241 <br /> MAILING ADDRESS 410. <br /> 685 W. Third Street <br /> CITY 417. STATE 418. ZIP CODE 419. <br /> Hanford CA 93230 <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- 1012141616101 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 /> oF. <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) <br /> r� <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that the information provided herein is true accurate and in full compliance with legal re uirements. <br /> APPLICANT SIGNATUREDATE 424. PHONE 4 425. <br /> (559) 583-3298 <br /> APPLICANT NAME(print) 426. APPLICANT TITLE + 427 <br /> Sandy Huff Compliance Coordinator <br /> UPCF UST-A Rev.(12/2007) <br />