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RE E[ <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK MAR 2 2 2 12 <br /> OPERATING PERMIT APPLICATION FACILITY INFORMATION <br /> (One form per facility) ENVIRONMENTAL HEALI <br /> Dona Al o ES <br /> TYPE OF ACTION ❑ 1.NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE <br /> (Check one iteni only) ® 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 411. FACILITY ID# <br /> I (Agency Use Only) <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 ® 1.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 410.1 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 94621 <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 CA 94621 <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- 103121219141 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 E] 4.TANK OPERATOR 423. <br /> ® 3.TANK OWNER ❑ 5.FACILITY OPERATOR 01 ,= <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required for Public Agencies Only) 406. <br /> VII. APPLICANT SIGNATURE - <br /> CERTIFICATION: 1 certify that the information provided herein is true,accurate,and in full com liance with legal re uirementsi: <br /> APPLICANIGNATURE DATE 424. PHONE 425. <br /> �Z�27�i/ (510) 636-2545 <br /> APPLICAM(e)e <br /> rmt) 4'-6 APPLICANT TITLE 427 <br /> Geor Dur Plant Engineering Area Manager <br /> UPCF UST-A Rev.(12/2007)-1/2 www.unidocs.org <br />