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dmkk NEW WEST PETROLEM Fax Aug 13 2009 10:28am P004 <br /> ED PROGRAM CONSOLXD,A,TED F <br /> UNDERGROLND STORAGE WANK <br /> OPERATING PERMfIT APPLICATION—FACILITY IN,F RMATXON a_!H G'► <br /> (One farm per facilliv) <br /> 4a0 <br /> TYPZ OF ACTION ❑ I.\r..w PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7,PERK NENT FACILITY CLOSURE <br /> (Check ong item only) I� 3.RENEWAL PERMIT ❑ 6.'I'EMPORARY FACILITY CLOSURE ❑ 9.TRS?`S FER PERyFIT <br /> X. FACILITY INFORMATION I <br /> TOTAL NUMBER OF USTs AT FACILiTY °R FACILITY ID# T _ _2 r�R �, use o,:rye 1 <br /> 171 <br /> RI.ISINESS NAME(Swnc as FACILITY NAME or DBA-Doing Buiffim A3) <br /> Flag City Shell <br /> BUSINESS SITE AI)DRE$$ 103• CITY 04, I <br /> 6437 W. Banner St. Lodi i <br /> - I <br /> FACILITY TYPE ® l MOTOR VFT.FHICFI.mrLN403. f-k g <br /> G ❑ 2.FULL DISTRIBUTION Is the ity located on Indian Reservation or 405. <br /> ❑ 3.FARM ❑ 4.PROCESSOR, Q 6.OTHER Trust Ii n is? ❑Yes ®No <br /> H. PROPERTY OVVNER IN1E'ORMATION <br /> PROPERTY OWNER NAME 407• PHON z40a <br /> J. Gilbert Moore 91E'h 443-0890 I <br /> 1.. <br /> MAILING ADDRESS 4015 <br /> 1831 16th Street <br /> CITY - -- --- 410 STATE L1 ZIP(( ,1E 4'z <br /> Sacramento i CA 1958-11 <br /> Ill, TANK OPERATOR INiFOXLMATION - <br /> TANK OPERATOR NAME 425-1 PHON <br /> New West Stations, Inc. (91E ) 443-0890 <br /> MAILING ADDRESS 42a'4 <br /> 1831 16" Street <br /> CI 421;.4 STATE 428.5 ZIP(:ODE, aas.e <br /> Sacramento CA 195811 <br /> IV. TANK OWNER INFORMATION � <br /> TAi\KO1,rNERNAME 414. PHONES ais <br /> J. Gilbert Moore (916.1443-0890 j <br /> 141:'!JLINCi ADDRESS IG <br /> 1831 166' Street <br /> CITY 417. STATE 418. i ZIPCOI)I~ 4!9 <br /> Sacramento CA 9581_1 <br /> I <br /> Q'>VNER'IYPE: ❑ 4.LOCAL AGENCY.'DISTRICT ❑ 5.COUNTY AGENCY C3 6.STATE AGENCY 40 <br /> ❑ 7.FfDFRAL AGL•NCY © 9.NON-C',Q FRNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOT_-N'T NUMBER <br /> TY(TK)HQ 44- 10 13 6 6 1 3 Call the State Board of Lqualization,Fuel?ax Divi ion,fifth-re are questions. <br /> V..PERMIT HOLDER INFORMATION Y i <br /> FISsu6 pvmit and smd)cgal noliflcations and Irmilings to: ❑ ).FACILITY Oh'.IFR ® 4.TANK OPERATOR ti,z <br /> ❑ 3.TANK OWNER ❑ 5,FACILITY{)PF.RATOf, <br /> OW, <br /> SUPERVISOR OF DIVISION,SECTION.OR OFFICE(Required For Public Agencies Only) <br />