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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION—FACILITY INFORMATION <br /> (One li+nn lxl lactha I <br /> TYPE 017 ACTION 1.NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CI t)St IRE ` <br /> (Chock(8tc nem only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE [19.TRANSFER PERMIT <br /> tA< {<'I�RAC1')[�t Y INFOVIATIONF <br /> TOTAL NUMBER OF USTs AT FACILITY 404, FACILITY ID 9 <br /> 3 (Agencp Use O„) <br /> BUSINESS NAME(sanwzrA('IUWNAME arD6A-WmgHwintmA,) <br /> ARCO ECONO GAS <br /> BUSINESS SITE ADDRESS 103 CITY 104 <br /> 880 E.VICTOR RD LODI <br /> FACILITY TYPE ❑ I.MOTOR VEHICLE FUELING 91 2.FUEL DISTRIBUTION 403 Is the facility located on Indian Reservation or 405 <br /> ❑ 3.FARM 4.PROCESSOR El 6.OTHER Trust lands'' ❑Yes ®No <br /> k PROPERTY OWNER INFORIHA'IIION <br /> PROPERTY OWNER NAME 407 PHONE 4W <br /> SUKH SINGH (209-369p0958 <br /> MAILING ADDRESS <br /> 880 E.VICTOR RD <br /> CITY 410. STATE 411 ZIP CODE 41: <br /> LODI CA 95240 <br /> wg <br /> � + STANK OpEITORIFORMA=TxOPT <br /> .yn1Y :...: <br /> r.4.F).... e <br /> TANK OPERATOR NAME 4215-1. PHONE <br /> SUKH SINGH (209-369-0958 <br /> MAILING ADDRESS <br /> 880 E.VICTOR RD <br /> CITY 4284 STATE 4215.5 'LIP CODE 4'15 x <br /> LODI CA 95240 <br /> TANK�-OWNER INEORMATIO�I: <br /> TANK OWNER NAME 414. PHONE 415 <br /> SUKH SINGH {209-364-0958 <br /> 416 <br /> MAILING ADDRESS <br /> 880 E.VICTOR RD <br /> "YO D{ 417. STATE CA 418 ZIPCODE 95240 41 <br /> L <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT Q 5.COUNTY AGENCY ❑ 6.STATE A(;[-'NC)' + <br /> ❑ 7.FEDERAL AGENCY L'I 8.NON-GOVERNMENT _ <br /> 1 ` $O b Q l iY A tiON I5T`STD G FE]± ACC�W NUMBER <br /> TY(TK)HQ 44- 'O 14 11 12 16 1 2 Call the State Board of Equalization,Fuel Tax Division,if ureic arc,wcsuam x' <br /> V ,VZ.spERMIT,HOI:DER INFORMATION <br /> 1]+ <br /> hmic permit and send legal notifications and mailings to: 8 1.FACILITY OWNER ❑ 4.TANK TOR <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> 415x, <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) <br /> 4. <br /> 4 it 7 � 4 <br /> YII APISIC,ANT SIGNATURE <br /> CERTIFICATION: 1 certify that the information provided herein is true,accurate,and in full compliance with legal requirements. <br /> IC NT JRE 424 PHONE 424 <br /> 11 DAT¢, I'2 ` ( ONE } 636-9500 <br /> APPLICANT NAME(print) 426 APPLICANTTITLE <br /> ITLE x' <br /> LUCY SILVAS-THOMAS PROJECT ADMINISTRATOR <br /> UPCF UST-A Rev.(12/2007) <br />