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010 ei�g I Ih oil <br /> UNIFIED PROGRAM SOL D FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION—FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION El I.NEW PERMIT [15.CHANGE OF INFORMATION ❑ 7 PERMANENT FACILITY CLOSURE 40D' <br /> (Check an loom Only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> AL NUMBER OF USTs AT FACILITY 404• <br /> 4 FACILITY ID#(Ageecy Uw OW 7-71 <br /> Jq <br /> BUSINESS NAM(9me n FACUM NUM orDBA-DoingBusinpsAs) 3. <br /> Walmart <br /> BUSINESS SITE ADDRESS 103. CITY 104, <br /> 3010 W Grant Line Rd Tracy, CA <br /> FACILITY TYPE ❑ 1 MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTIONIs the facility located on Indian Reservation or 405. <br /> 3.FARM 4.PROCESSOR 6.,2Wfa Trust lands? ❑Yes ®No <br /> im ^p K <br /> PROPERTY OWNER NAME <br /> Walmart Real Estate Business Trust eros. <br /> 479 204-0220 <br /> MAILING 2001 SE 10th Street409. <br /> CITY ata STATE 411• ZIP CODE 417 <br /> Bentonville AR 72716 <br /> TOR Ido <br /> 10ft(A r . <br /> TANK OPERATOR NAME 4*1. <br /> PHONE aza-z <br /> Walmart Stores Inc. 479 ) 204-0220 <br /> MAILING ADDRESS 428-3 <br /> 702 SW 8th St. <br /> CITY 4P4 STATE 4284�7T <br /> P CODE 428 <br /> Bentonville AR 2716 <br /> OWR <br /> TANK OWNER NAME 414. PHONE 415. <br /> Walmart Stores Inc. 479 )204-0220 <br /> MAILING ADDRESS ata <br /> 702 SW 8th ST. <br /> CITY 417• STATE 418. ZIp Qpg 419, <br /> Bentonville AR <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 42a <br /> [3 7.FEDERAL AGENCY ® S.NON-DOVER AdENT <br /> s7. <br /> TY(1K)AQ 44- Call the State Board ofEqualimtion,Fuel Tax Division,ifthere are questions, a21. <br /> law permit and send legal notifications and matthW to: ® 1.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) 4 <br /> CERTIFICATION: I cerli that the information rovided!! ,i,trne,acctva aed in full com Bance!pHp requirements. <br /> P IC SIGN RE DATE aaa. 425. <br /> ' <br /> APPLICANT NAME(print) 426. APPLICANT TITLE as <br /> Chelsea Covington Maass P rmit Coordinator, BRR Architecture <br /> UPCF UST-A Rev.(12/21107) <br />