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M3� II <br /> IWIED PROGRAM CONSOLIDATED FOAM <br /> UNDERGROUNDSTORAGETANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> .. ,(One form per facility) <br /> TYPE OF ACTION ❑ I.NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400. <br /> (Check one item only) ® 3.RENEWAL PERMIT <br /> ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMSAR Q <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404' FACILITY ID 4 <br /> (Agency Use Only) <br /> BUSINESS NAME(same m FACILITY NAME or DBA-Doing Business As) 3 <br /> Emil's Liquor&Sport Shop <br /> BUSINESS SITE ADDRESS 103- CITY 104 <br /> 1405 California Street Escalon 95320 <br /> FACILITY TYPE E I.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 /> IL PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407_ PHONE 408. <br /> Chacko Thomas 209 838-7674 <br /> MAILING ADDRESS 409. <br /> 1405 California Street <br /> CITY 410, STATE 411. ZIP CODE 412. <br /> Escalon CA 95320 <br /> IH. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. PHONE 428-2 <br /> Chacko Thomas (209) 838-7674 <br /> MAILING ADDRESS 428.3 <br /> 1405 California Street <br /> CITY 428-4 STATE 428-5 ZIP CODE 428-6 <br /> Escalon CA 95320 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> Chacko Thomas (209) 499-2693 <br /> MAILING ADDRESS 416, <br /> 1409 Michelle Way <br /> CITY 417. STATE 418. ZIP CODE 419. <br /> Escalon CA 95320 <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, 0 4 6 5 $ 8 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: ® I.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 'NATURDATE 424 PHONE r-I 425- <br /> 5/3/2011 (209) 838-7674 <br /> APPLICAMT NAME print) 426. APPLICANT TITLE 427 <br /> Linda Martin Manager <br /> UPCF UST-A Rev.(12/2007) <br />