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IED PROGRAM CONSOLIDATED FO <br />UNDERGROUND STORAGE TANK a �� <br />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 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 <br />ID # <br />T(AgencyUse <br />- <br />- <br />1 <br />4 <br />3 <br />2 <br />5 <br />1 <br />9 <br />Only) <br />BUSINESS NAME (Same as FACILITY NAME or DBA -Doing Business As) 3. <br />Prime Shine Express <br />BUSINESS SITE ADDRESS 103- <br />CITY 104. <br />301 W. Kettleman Ln <br />Lodi <br />FACILITY TYPE ❑ 1. MOTOR VEHICLE FUELING ❑ 2. FUEL DISTRIBUTION 403• <br />Is the facility located on Indian Reservation or 405. <br />❑ 3. FARM ❑ 4. PROCESSOR ® 6. OTHER <br />Trust lands? ❑ Yes ® No <br />II. PROPERTY OWNER INFORMATION <br />PROPERTY OWNER NAME 407, <br />PHONE 408. <br />Ivern V. & Iona Baffoni Tr. Et. Al. <br />( ) <br />MAILING ADDRESS 409. <br />P.O. Box 3469 <br />CITY 410. <br />FSTATE 411. <br />ZIP CODE 412• <br />Modesto ICA <br />95353 <br />III. TANK OPERATOR INFORMATION <br />TANK OPERATOR NAME 428-1• <br />PHONE 428-'- <br />Norm Porges <br />(209) 549-9274 <br />MAILING ADDRESS 428-3 <br />P.O. Box 3469 <br />CITY 4284 <br />STATE 428-5 <br />ZIP CODE 428-6 <br />Modesto ICA <br />95353 <br />IV. TANK OWNER INFORMATION <br />TANK OWNER NAME 414, <br />PHONE 415. <br />Norm Porges <br />(209) 549-9274 <br />MAILING ADDRESS 416. <br />P.O. Box 3469 <br />CITY 417. <br />STATE 418. <br />ZIP CODE 419. <br />Modesto <br />CA <br />95353 <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- 1Call 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 />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 with legal re uirements. <br />APPLICANT SIGNATURE <br />DATE 424• <br />PHONE 425. <br />) <br />APPLICANT NAME (print) 426. <br />APPLICANT TITLE 427 <br />UPCF UST -A Rev. (12/2007) <br />