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e� <br /> "IFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK 18 <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> 201 <br /> One form per facility) <br /> TYPE OF <br /> ACTION ❑ 1.NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FA <br /> ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ® 9.TRANSFER PERMIT <br /> Check one item onl <br /> e <br /> v ,< ..aa,, a ,`* sir�,'°z s� ',w aa=°m_ v, :. .S,s�'.�x,iIuc x�;„✓e>a a,lw „-"SF"'��''.*. <br /> TOTAL NUMBER OF USTs AT FACILITY ` � t <br /> 404. FACILITY ID# 6 <br /> 2 A en Use t?n[ .: <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doig Bulinus As) 3. <br /> Pacific Avenue Chevron <br /> BUSINESS SITE ADDRESS 103. CITY 104. <br /> 6633 Pacific Ave. Stockton,CA 95207 <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 n 6.OTHER <br /> Trust lands? ❑Yes ®No <br /> '. s, <br /> PROPERTY OWNER NAME 407 PHONE 408. <br /> American Petroleum,LLC (9161488-3666 <br /> MAILING ADDRESS 409• <br /> P.O.Box 1096 <br /> CITY 410. STATE 411. ZIP CODE 412. <br /> Carmichael y1�-r.)I CA 95609 <br /> TANK `1 �� ,y AY <br /> TANK OPERATOR NAME 428-1. PHONE 428.2 <br /> Edward R.Marszal Ente rises Inc. (916)488-3666 <br /> MAILING ADDRESS 428-3 <br /> P.O.Box 1096 <br /> CITY 428.4 STATE 428-5 ZIP CODE 428-6 <br /> Carmichael CA 95609 <br /> u" ' <br /> z a <br /> r :T� € <br /> s r <br /> ;>°�ir,4&.5'..:ka�' � v "r<5u.s .v.�.,✓�a, ,ur,# < osau-oW. .,.u..ua�. a �.' �tw....:,;> s .: ')lwkk, �.'.`cv'"...2,r <br /> TANK OWNER NAME 414. PHONE 415. <br /> American Petroleum,LLC (916)488-3666 <br /> MAILING ADDRESS 416. <br /> P.O.Box 1096 <br /> CITY an. STATE 418, ZIP CODE 419. <br /> Carmichael 195609 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY ® 8.NON-GOVERNMENT <br /> M <br /> MM <br /> TY K H 44- 1 0 1 4 1 4 1 7 1 2 2 1 Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421. <br /> �� P Edi Y O► � �� <br /> :3 xS' a aw.... �.✓ r. .....i» .: a. ........... .. Aa...., ,. .< a,kw. .. .a':c>,.v..,k.._ t <br /> Issue permit and send legal notifications and mailings to: ❑ L FACILITY OWNER ® 4.TANK OPERATOR 423 <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) 446. <br /> }� <br /> .x. ``"" $ �. <br /> `k a. <br /> CERTIFICATION: I certify that the information prmided herein is true,accurate,and in full compliance with 1 al r uirements. <br /> AP I SIG DATE 424• 1 PHONE 425• <br /> 10/14/14 916 488-3666 <br /> APP NAME(print) 426. APPLICANT TITLE 427 <br /> JennlWett Director of Finance <br /> UPCF UST-A Rev.(12/2007) <br />