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1 <br /> i <br /> I <br /> i <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK f <br /> OPERATING PERMIT APPLICATION - FACILITY INFORMATION I <br /> (One form per facility) <br /> TYPE OF ACTION [X 1 , NEW PERMIT ❑ 5 , CHANGE OF INFORMATION ❑ 7. PERMANENT FACILITY CLOSURE 400' 1 <br /> (Check one item only) ❑ 3, RENEWAL PERMIT ❑ 6. TEMPORARY FACILITY CLOSURE ❑ 9 . TRANSFER PERMIT <br /> I. FACILITY INFORMATION 1 <br /> TOTAL NUMBER OF USTs AT FACILITY 404• FACILITY ID # IM77 <br /> [ (Agency Use Only) <br /> BUSINESS NAME (Same as FACILITY NAME or DBA —Doing Business As) 3. 1 <br /> Harney 76 <br /> BUSINESS SITE ADDRESS 103, <br /> 141 E . Harney Lane CITY 104,Lodi <br /> FACILITY TYPE ® 1 . MOTOR VEHICLE FUELING ❑ 2. FUEL DISTRIBUTION 403' Is the facility located on Indian Reservation or 4050 l <br /> ❑ 3 . FARM ❑ 4. PROCESSOR ❑ 6e OTHER Trust lands? ❑ Yes ® No ! <br /> i <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 408. <br /> D . N . Acquisitions , LLC 09 518 - 3496 <br /> MAILING ADDRESS 409, <br /> 10940 Trinity Pkwy , C-274 <br /> CITY 410• STATE 411• ZIP CODE alz <br /> Stockton CA 95219FF <br /> { <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 42114 • PHONE 429-2 <br /> Avin Shaan Investments , LLC X209 518 -3496 <br /> MAILING ADDRESS 428.3 I <br /> 5453 Cosumnes Dr. <br /> CITY 4284 STATE 428-5 ZIP CODE 428-6 <br /> FFFF <br /> Stockton CA 95219 j <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414, PHONE 415, 1 <br /> Avin Shaan Investments , LLC ( 209 518 - 3496 <br /> MAILING ADDRESS 1 416. ! <br /> 10940 Trinity Pkwy . C-274 <br /> CITY 417, STATE 419, ZIP CODE 419. 1 <br /> Stockton <br /> CA 95219 I <br /> OWNER TYPE: El 4o LOCAL'AGENCY/DISTRICT El5, COUNTY AGENCY ❑ 6. STATE AGENCY 420• I <br /> ❑ 7. FEDERAL AGENCY . ® 8. NON-GOVERNMENT j <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNTNUMBER <br /> TY (TK) HQ 44- Call the State Board of Equalization, Fuel Tax Division, if there are questions. 11 421 ' <br /> IF I <br /> VI. PERMIT HOLDER INFORMATION i <br /> Issue permit and send legal notifications and mailings to: ❑ 1 . FACI;,ITY *OWNER [ 4. TANK OPERATOR 423 <br /> ❑ 3 . TANK OWNER ❑ <br /> 5:-FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION, SECTION, OR OFFICE (Required For Public Agencies Only) , ' <br /> 4064 i <br /> i <br /> VII. APPLICANT SIGNATURE <br /> CERTIFICATION : I certify that the information provided herein is true, accurate, and in full compliance with legal re uirements, <br /> APPL ANT SIGNATURE DATE 424. P80NE 425, <br /> ! . ; 6/2/2020 209 518 - 3496 <br /> APPLICANT N not 426• APPLICANT TITLE 427 1 <br /> Sandeep S� Dnanda Managing Member <br /> UPCF UI Rev. (12/2007) <br /> i <br /> I <br />