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f -fM� 1 <br /> UNIFIED PROGRAM CONSOLIDATED FO /,71// <br /> UNDERGROUND STORAGE TANK // <br /> OPERATING PERMIT APPLICATION—FACILJ FORMA I N <br /> 10 . <br /> 3 2�' Ju e form per facility) <br /> TYPE OF ACTION ❑ 1.NEW PERMIT ❑ 5.CHANGE OF INFORMATION PE ENT 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. FACILITY D# _ _ �} I <br /> I (4gency Use Only) p( <br /> BUSINESS NAME(Same as FACILITY NAME or DBA—Doing Business As) 3. <br /> San Joaquin County Records Center <br /> BUSINESS SITE ADDRESS 103 CITY 104, <br /> 630 N.California Street Stockton <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 ® 6.OTHER Trust lands? ❑Yes ®No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 408, <br /> San Joaquin County (209)468-9625 <br /> MAILING ADDRESS 409, <br /> 44 N. San Joaquin Street, Suite 590 <br /> CITY 410, 1 STATE 411. ZIP CODE 412. <br /> Stockton CA 95202 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1 PHONE 428-2 <br /> UNKNOWN ( ) <br /> MAILING ADDRESS 428-3 <br /> CITY 428-4 STATE 428-5 ZIP CODE 428-6 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414, PHONE 415 <br /> UNKNOWN <br /> MAILING ADDRESS 416, <br /> CITY 417 1 STATE 418 ZIP CODE 419. <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 /> TY(TK)HQ 44- Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421. <br /> VI.PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings 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)Gabe Karam-Capital Projects 406, <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that the information provided herein is true accurate,and in full com fian424.ce with legal re uirement?." <br /> APPL IGNAT � DATE PHONE ves. <br /> (209) 234-0518 i <br /> APPLICANT NAME(print) 426 APPLICANT TITLE L_:: 427 <br /> Alex Dewitt Pro'ect Manager,Condor Earth Technologies,Inc. <br /> " " p, <br /> l �,pOZ <br /> UPCF UST-A Rev.(12/2007) <br /> L <br />