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6 0 -x(61 021'1R <br />UNIFIED PROGRAM CONSOLIDATED FORM <br />7G <br />UNDERGROUND STORAGE TANK <br />OPERATING PERMIT APPLICATION •- FACILITY INFORMATION <br />(Orc form per facility) <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' <br />FACILITY ]D N <br />_ <br />d <br />Q <br />�} <br />3 <br />�J <br />4 <br />(Agency Use Only) <br />/ <br />BUSINESS NAME (Same as FACILITY NAME or DBA — Doing Business As) 3 <br />P 9-023 2Lf(o <br />Grant Line Shell <br />BUSINESS SITE ADDRESS 1e3. <br />CITY 104 <br />2375 W. Grant Line Road <br />Trac <br />FACILITY TYPE ® 1. MOTOR VEHICLE FUELING [:12. FUEL DISTRIBUTION 403 <br />' <br />Is the facility located on Indian Reservation or 4os. <br />Trust lands? ❑ Yes Z No <br />❑ 3. FARM ❑ 4. PROCESSOR ❑ 6. OTHER <br />II, PROPERTY, OWNER INFORMATION <br />PROPERTY OWNER NAMEA A M n i �� j HONE 408• <br />(� V <br />909-394-4728 <br />409, <br />MAILING ADDRESS <br />1040 N. BENSON AVE. <br />CITY 410 <br />STATE 411• <br />ZIP CODE 412• <br />Upland <br />CA <br />91786 <br />III. TANK OPERATOR INFORMATION <br />TANK OPERATOR NAME 428-1• PHONE 428.2 <br />RADC Enterprises Inc. 909-394-4728 <br />4za•3 <br />MAILING ADDRESS <br />1040 N. Benson Ave, <br />CITY 428-4 STATE 428.5 ZIP CODE 428.6 <br />Tracy CA 95377 <br />IV. TANK OWNER INFORMATION <br />TANK OWNER NAME 414. PHONE 415• <br />RADC Enterprises Inc. 909-394-4728 <br />416. <br />MAILING ADDRESS <br />1040 N. BENSON AVE. <br />CITY 411• <br />STATE 418. <br />ZIP CODE 419. <br />Upland <br />CA <br />91786 <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 />421. <br />TY (TK) HQ 44- <br />O <br />4 <br />1 8 <br />1 11 <br />1 <br />1 8 <br />1 Call the State Board of Equalization, Fuel Tax Division, if there are questions, <br />VI. PERMIT.HPLDER INFORMATION <br />423 <br />issue permit and send legal notifications and mailings to: ® 1. FACILITY OWNER ❑ 4. TANK OPERATOR <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 />CERTIFICA ION: I certify that a infewmation provided herein is true accurate and in full compliance with legal re uiremen a: r <br />APPLICANT AGNATUR.E DATE 424. PHONE s 425• <br />' 1/25/2011 909-394-47287 <br />1 <br />APT AME (print) 426. <br />1:96 e <br />ACANTITL 427 <br />Wa a <br />ma <br />UPCF UST -A Rev, (12/2007) <br />y1u <br />