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Adm.- b IU <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION El1.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# . _ L` ♦ t> I <br /> 4 (Agency Use Only) <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3. <br /> Tracy Blvd Shell <br /> BUSINESS SITE ADDRESS 103. CITY 104. <br /> 3725 N. TracyBoulevard Trac <br /> FACILITY TYPE ® I.MOTOR VEHICLE FUELING El 2.FUEL DISTRIBUTION 403. Is the facility located on Indian Reservation or 4os. <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6,OTHER Trust lands? ❑Yes ®No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408. <br /> RADC Enterprises Inc. 909-394-4728 <br /> 409 <br /> MAILING ADDRESS <br /> 1040 N. BENSON AVE. <br /> CITY 410, 1 STATE 411. ZIP CODE 412. <br /> Upland CA 91786 <br /> M. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428.1, 1 PHONE 428-2 <br /> RADC Enterprises Inc. 909-394-4728 <br /> 428.7 <br /> MAILING ADDRESS <br /> 1040 N. Benson Ave. <br /> CITY 428.4 STATE 428•-2 ZIP CODE 428-6 <br /> Tracy CA 195304 <br /> IV. TANK OWNER INFORMATION ��Nj\ <br /> CTANK OWNER NAME 414, PHONE 415• <br /> RADC Enterprises Inc. 909-394-4728 <br /> MAILING ADDRESS 416. <br /> 1040 N. BENSON AVE. <br /> CITY 4n. STATE 418. ZIP CODE 419. <br /> Upland CA 91786 <br /> -OWNERTYPE: ❑ 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 /> 421. <br /> TY(TK)HQ 44- 0 1418 .1 1 1 $ 5 Call the State Board of Equalization,Fuel Tax Division,if there are questions. <br /> VI.PERMIT HOLDER INFORMATION <br /> 423 <br /> Issue permit and send legal notifications and mailings to: ® 1.FACILITY OWNER El4.TANK OPERATOR <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) 406. <br /> VII,APPLICANT SIGNATURE <br /> CERTIF ATION: I certif that the information rovided herein is true,accurate,and in full compliance with legal tl!�uiroments. <br /> APPLICA SIGNATURE DATE 424• PHONE ,� 425' <br /> ,�/ 1/25/2011 909-391-47,28 42� <br /> CANT NAME(print) _ 426• APPLICANT TITLE <br /> _ <br /> UPCF UST-A Rev.(12/2007) 1 <br />