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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 400. <br /> (Check one Nem only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY a°a. FACILITY ID# _ LL_ <br /> l <br /> 3 (Agency Use Only) <br /> BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3. <br /> H & M MARKET <br /> BUSINESS SITE ADDRESS 103. CITY 104. <br /> 2501 JACKSON AVE. ESCALON, CA. 95320 <br /> FACILITY TYPE ® 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403' Is the facility located on Indian Reservation or nus. <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑ 1.Yes Z 2.No <br /> H. PROPt RTY-OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 408, <br /> PHILLP MATTHEWS (408) 336-2549 <br /> MAILING ADDRESS 409, <br /> 532 COON HEIGHTS RD. <br /> CITY 419. STATE 411. ZIP CODE 112 <br /> BEN LOMOND ICA 95005 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 42a-1. I PHONE 428-2. <br /> B &W PETROLEUM (209) 577-6000 <br /> 42aa. <br /> MAILING ADDRESS <br /> 601 Mc HENRY AVE. <br /> CITY 429-4. STATE aze•s. ZIP CODE 428-6. <br /> MODESTO CA 95350 <br /> IV.-TANK OWNER IN=FORMATION <br /> TANK OWNER NAME ala. PHONE nis. <br /> B &W PETROLEUM (209) 577-6000 <br /> 416. <br /> MAILING ADDRESS <br /> 601 Mc HENRY AVE. <br /> CTTh a17. STATE 41 s. ZIP CODE 419. <br /> MODESTO CA 95350 _ <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- 0 2 9 0 5 8 Call the State Board of Equalization,Fuel Tax Division,if there are questions. <br /> VI.PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: ❑ 1.FACILITY OWNER ® 4.TANK OPERATOR <br /> 423. <br /> ® 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Requiredfor Public Agencies Only) 406. <br /> VII. APPLICANT SIGNATURE <br /> CERTIFICATION: I cer0fildid thiinforrqation provided herein is true,accurate,and in full compliance with legal requirements, <br /> APPLICANT SIGNAT DATE ata 1 PHONF. 47.5. <br /> M7/22/2010 209) 577-6000 <br /> APPLICANT NAME(print) 1 426• APPLICANT TITLE 427 <br /> B &W PETROLE c/o ROHDA HENRY CUSTOMER SERVICE COORDINATOR <br /> CIPCF UST-A Rev.(12/2007)-1/2 www.tinidocs.org <br />