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o0 25 3 a5�o (o <br /> UNIFIED PROGRAM CONSOLIDATED FORM C� I ' <br /> UNDERGROUND STORAGE TANK <br /> LL OPERATING PERMIT APPLICATION - FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION ❑ 1 . NEW PERMIT ❑ 5. CHANGE OF INFORMATION ® 7. PERMANENT FACILITY CLOSURE 4D0. <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 ID # <br /> 1 A crpnry Use Only ' <br /> BUSINESS NAME (same as FACILITY NAME or DBA - Doing Business As) 3 _ <br /> DBL Rentals <br /> BUSINESS SITE ADDRESS 103. CITY 104. <br /> 619 and 625 North Sacremento Street Lodi, CA <br /> FACILITY TYPE ❑ L 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 /> John Bubica 209 625 -5261 <br /> MAILING ADDRESS 409, <br /> 701 South Ham Lane Suite C <br /> CITY 410. STATE 411 . ZIP CODE 412• <br /> Lodi CA 95242 <br /> M. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. PHONE 428-2 <br /> John Bubica (209) 625 -5261 <br /> MAILING ADDRESS 428-3 <br /> 701 South Ham Lane Suite C <br /> CITY 428-4 STATE 428-5 1 ZIP CODE 428-6 <br /> Lodi CA 95242 <br /> IV, TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> John Bubica (209) 625 -5261 <br /> MAILING ADDRESS 416. <br /> 701 South Ham Lane Suite C <br /> CITY 417. STATE 418. ZIP CODE 419. <br /> Lodi CA 95242 <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 [14. 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 /> APP fANJAIG RE DATE 424. PHONE 425. <br /> 426. 427ATIPLIC T NAME11 (print) /�uYWL e { / <br /> UPCF UST-A Rev. ( 12/2007) <br />