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i*7A 6PIC <br />l'vdc 7 / UNIFIED PROGRAM CONSOLIDATED FORM <br />UNDERGROUND STORAGE TANK <br />OPERATING PERMIT APPLICATION - FACILITY INFORMATION <br />(One form per facility) <br />UPCF UST -A Rev. (12/2007) <br />TYPE OF ACTION ❑ 1. NEW PERMIT <br />❑ 5. CHANGE OF INFORMATION R 7, PERMANENT FACILITY CLOSURE <br />400. <br />(Check one item only) ❑ 3. RENEWAL PERMIT ❑ 6. TEMPORARY FACILITY CLOSURE ❑ 9. TRANSFER <br />PERMIT <br />I. FACILITY INFORMATION <br />TOTAL NUMBER OF USTs AT FACILITY <br />404. <br />FACILITY ID # <br />_ <br />_ <br />I, <br />2 <br />(Agency Use Only) <br />BUSINESS NAME (same m FACILITY NAME or DBA <br />-Doing Business As) <br />3, <br />Holly Commerce Center LLC <br />BUSINESS SITE ADDRESS <br />103. <br />CITY <br />too. <br />20500 Holly Drive <br />Tracy <br />FACILITY TYPE F11. MOTOR VEHICLE FUELING El 2* FUEL DISTRIBUTION 403' <br />Is the facility located <br />on Indian Reservation or <br />4os. <br />❑ 3. FARM ❑ 4. PROCESSOR W 6, OTHER <br />Trust lands? ❑ Yes J91 No <br />H. PROPERTY OWNER INFORMATION <br />PROPERTY OWNER NAME <br />40T <br />PHONE <br />408. <br />Holly Commerce Center LLC <br />925 <br />283-8777 <br />MAILING ADDRESS <br />409. <br />21 Lafayette Circle, Suite 200 <br />CITY <br />410, <br />STATE 411. <br />ZIP CODE <br />412. <br />Lafayette <br />CA <br />94549 <br />HI. TANK OPERATOR INFORMATION <br />TANK OPERATOR NAME <br />428-1. <br />PHONE <br />428-2 <br />Same as Property Owner <br />MAILING ADDRESS <br />428-3 <br />CITY <br />428-4 <br />STATE 428-5 <br />ZIP CODE <br />428-6 <br />IV, TANK OWNER INFORMATION <br />TANK OWNER NAME <br />414. <br />PHONE <br />415. <br />Same as Property Owner <br />MAILING ADDRESS <br />416. <br />CITY <br />417. <br />STATE 418. <br />ZIP CODE <br />419. <br />OWNER TYPE: ❑ 4. LOCAL AGENCY/DISTRICT ❑ 5. COUNTY AGENCY ❑ <br />6. STATE AGENCY <br />ago. <br />❑ 7. FEDERAL AGENCY 8, NON-GOVERNMENT <br />V. BOARD OF <br />EQUALIZATION UST STORAGE FEE ACCOUNT <br />NUMBER <br />TY (TK) HQ 44- <br />1 <br />1 Call the State Board of Equalization, Fuel Tax Division, if there are questions. <br />421. <br />VI. PERMIT HOLDER INFORMATION <br />Issue permit and send legal notifications and mailings to: [, 1. FACILITY OWNER El4. <br />TANK OPERATOR <br />423 <br />❑ 3. TANK OWNER ❑ <br />5. FACILITY OPERATOR <br />406. <br />SUPERVISOR OF DIVISION, SECTION, OR OFFICE (Required For Public Agencies Only) <br />VII. APPLICANT SIGNATURE <br />CERTIFICATION: I certify that the information provided herein is true, accurate, and in full compliance <br />with legal requirements. <br />APPLICANT SIG ATUR <br />DATE 424• <br />PHONE <br />425. <br />5/5/21 <br />415 533-0112 <br />APPLICANT AME (p nt) <br />426. <br />APPLICANT TITLE <br />427 <br />Adam Burton <br />President - Costera Waste & <br />Environmental, Inc. <br />UPCF UST -A Rev. (12/2007) <br />