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0 RECEIVED <br /> UNIFIED PROGRAM CONSOLIDATED FORM JUL 1 <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION FACILITY INFO A <br /> (One form per facility) PERMIT(SERVICES <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[D# <br /> ef I (Agency Use Only) <br /> I F <br /> BUSINESS NAME(Same as Facility Name or DBA Doing Business As) 3. <br /> United Parcel Service Inc., an Ohio Corporation <br /> BUSINESS SITE ADDRESS 103. CITY 104. <br /> 1532 North Broadway Stockton <br /> FACILITY TYPE ® I.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403. Is the facility located on Indian Reservation or 405. <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 /> BT-OH, LLC (404) 828-7660 <br /> MAILING ADDRESS 409, <br /> 55 Glenlake Parkway, NE <br /> CITY 410. STATE 411. ZIP CODE 412. <br /> Atlanta GA 30328 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. PHONE 428-2 <br /> United Parcel Service Inc., an Ohio Corporation (510) 633-4035 <br /> MAILING ADDRESS 428-3. <br /> 8400 Pardee Dr <br /> CITY 428-4. STATE 428.5• ZIP CODE 428-6. <br /> Oakland CA 194621 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415, <br /> United Parcel Service Inc., an Ohio Corporation (510) 633-4035 <br /> MAILING ADDRESS 416. <br /> 8400 Pardee Drive <br /> CITY 417. 1 STATE 418. ZIP CODE 419, <br /> Oakland I CA 194621 <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- 013 2 2 9 4 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 El4.TANK OPERATOR 423. <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 /> CERTIFICATION: IS4"ify that the information provided herein is true,accurate and in full compliance with legal re uirements. <br /> APPLICA SIGNAT E DATE 424 PHONE 425. <br /> 1/2-- (510) 636-2545 <br /> APPLI T N (print) 426 APPLICANT TITLE 427 <br /> Ge a rkee Plant Engineering Area Manager <br /> UPCF UST-A Rev.(12/2007)-1/2 www.unidocs.org <br />