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0 0 <br /> 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 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 11 <br /> (Agency Use Only) <br /> BUSINESS NAME(Same as Facility Name or DBA—Doing Business As) 3 <br /> Trac Shell <br /> BUSINESS SITE ADDRESS 103. CITY 104 <br /> 3725 Trac Blvd Trac <br /> FACILITY TYPE [31.MOTOR VEHICLE FUELING ® 2.FUEL DISTRIBUTION 403' Is the facility located on Indian Reservation or 40S <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 /> Anabi Real Estate Development LLC 909 394 4728 <br /> MAILING ADDRESS 499 <br /> 1040 North Benson Ave <br /> CITY 41°. STATE 411. ZIP CODE alz <br /> Upland CA 91786 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 426.1. 1 PHONE 428.2. <br /> RADC Inc (909) 394 4728 <br /> MAILING ADDRESS 428"3 <br /> 1040 North Benson Ave <br /> CITY 428 4 STATE 428 5. ZIP CODE 42". <br /> Upland I CA 91786 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415 <br /> Anabi Real Estate Development LLC (909)394 4728 <br /> MAILING ADDRESS 418 <br /> 1040 North Benson Ave <br /> CITY 417 STATE 41& ZIP CODE 419 <br /> Upland I CA 91786 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420 <br /> ❑ 7.FEDERAL AGENCY ® S.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY UK)HQ 44- 1 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(Required for Public Agencies Only) 40& <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that the information provided herein is true,accurate,and in full com lia ice with legal r uirements. <br /> APPLICANT SIGNATURE DATE 42.4 PHONE szs. <br /> 17/19/2010 888 700 3742 x700 <br /> APPLICANT NAME(print 426. APPLICANT TITLE 427 <br /> Fadi Afa AI-Refaee Agent for Owner <br /> UPCF UST-A Rev.(12/2007)-1/2 www.unkWcsorg <br />