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FIED PROGRAM CONSOLIDATED FAR UNDERGROUND STORAGE TANK OPERATING PERMIT PLICATION-FACILITY INFORMATION (One form per facility) TYPE OF ACTION X 1.NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400. (Check one item only) ❑ 3 RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT I. FACILITY INFORMATION TOTAL NUMBER OF USTs AT FACILITY 404' FACILITY ID# _ [JTJ_ I '- 3 (Agency Use Only) BUSINESS NAME(Same as FAMITY NAME or DBA-Doing Business As) 3. New West#1003 BUSINESS SITE ADDRESS 103. CITY 104. 6437 W. Banner Road Lodi FACILITY TYPE x 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403 Is the facility located on Indian Reservation or 405. ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑Yes x No II. PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407. PHONE 408. New West Stations 916-443-0890 MAILING ADDRESS 409. 1831 16" Street CITY 410 1 STATE 411. ZIP CODE 412. Sacramento CA 95814 III. TANK OPERATOR INFORMATION TANK OPERATOR NAME 428-1. PHONE 428-2 New West Stations 916-443-0890 MAILING ADDRESS 428-3 1831 16th Street CITY 428-4 t STATE 428-5 ZIP CODE 428-6 Sacramento CA 95814 IV. TANK OWNER INFORMATION TANK OWNER NAME 414, PHONE 415. New West Stations 916-443-0890 MAILING ADDRESS 416. 1831 16th Street CITY 417, 1 STATE 418. ZIP CODE 419, Sacramento CA 95814 OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. ❑ 7.FEDERAL AGENCY X 8.NON-GOVERNMENT V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY(TK)HQ 44- 1 1 1 1 1 1 1 Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421. VI.PERMIT HOLDER INFORMATION Issue permit and send legal notifications and mailings to: ❑ 1.FACILITY OWNER [1 4.TANK OPERATOR 423 X 3.TANK OWNER ❑ 5.FACILITY OPERATOR SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) 406. VII.APPLICANT SIGNATURE CERTIFICATION: I certify that the information provided herein is true,accurate,and in full compliance with legal re uirements. APPLICANT TURE DATE 424. PHONE 425. i 4----- l0 --I- CA (916) 373-1166 APPLICANT N (print) 426. APPLICANT TITLE 427 Dulcinea Webb Compliance Manager UPCF UST-A Rev.(12/2007)