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' UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK 5 <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facility)) Lj <br /> ® El OF ACTION 1.NEW PERMIT 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOS V .1 y <br /> 0 � j <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' 1 FACILITY ID# 1 <br /> 3 (Agency Use Only) <br /> BUSINESS NAME(Same as FACELM NAME or DBA-Doing Business As) 3 <br /> C-Store w/ 76 Fuel Island and Carwash <br /> BUSINESS SITE ADDRESS 103 CITY 104 <br /> 141 E. Harney Ln. Lodi <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 40Z PHONE 408 <br /> DN Partners, LLC. c/o Omair Nasim 916 ) 807-4076 <br /> MAILING ADDRESS 409 <br /> 10940 Trinity Parkway, C-274 <br /> CITY 410. 1 STATE 411. ZIP CODE 412, <br /> Stockton CA 95219 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. PHONE 428-2 <br /> Same as property owner ( ) <br /> MAILING ADDRESS 428-3 <br /> CITY 4284 1 STATE 428-5 ZIP CODE 428-6 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415 <br /> Same as property owner ( ) <br /> MAILING ADDRESS 416 <br /> CITY 417. 1 STATE 418. ZIP CODE Ore. <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- 1 1 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) 406. <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that the information provided herein is true,accurate,and in full compliance with legal requirements. <br /> APPLICANT SIGNATURE DATE .124, PHONE 425. <br /> 916 807-4076 <br /> APPLICANT NAME(print) 426. APPLICANT TITLE 427 <br /> Omair Nasim <br /> UPCF UST-A Rev.(12/2007) <br />