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ILVF- <br /> tEMFIED PROGRAM CONSOLIDATED FOfwrT 0 6 <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facility) <br /> 71 <br /> TYPE OF ACTION ❑ 1.NEW PERMIT ® 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE <br /> (Check one nem 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#1y) _ _ 13 <br /> �1 - I <br /> 5 enc Use l7nCJ <br /> BUSINESS NAME(Smie m FACIL=NAW or DBA-Doing Besm.As) 3_ <br /> VANCO TRUCK&AUTO PLAZA <br /> BUSINESS SITE ADDRESS 103. CITY 100 <br /> 1033 W. CHARTER WAY STOCKTON <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 ao7. PHONE 408. <br /> NCC PROPERTIES PTP (209)465-3421 <br /> MAILING ADDRESS 409. <br /> P.O BOX 1107 <br /> CITY 410. STATE 411. ZIP CODE 411 <br /> STOCKTON I CA 95201 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME42a-1. PHONE 42 2 <br /> NEKE BOPARAI (209)466-0833 <br /> MAILING ADDRESS 428'3 <br /> 1033 W. CHARTER WAY <br /> CITY 4284 1 STATE 478-5 ZIP CODE 4}Sa <br /> STOCKTON CA 95206 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415, <br /> Mp{E BOPARAI 209 466-0833 <br /> MAILING ADDRESS 415_ <br /> 1033 W CHARTER WAY <br /> CITY 417. 1 STATE 418. ZIP CODE 419, <br /> STOCKTON CA 95206 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ S.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- 1014131816101 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.FACILITYOWNER ❑ 4.TANK OPERATOR 423 <br /> ® 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> a04. <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION- I cert that the information provided herein is true,accurate,and in full compliance with legal requke� <br /> APPLICANT SIGN E DATE 424 PHONE 4ss <br /> 6/9/2009 (209)466-0833 K, <br /> APPLICANT ) 426 APPLICANT TITLE 427 <br /> MACE BOPARAI OWNER Cj <br /> rro4c nem d 0.... n�nrun3 <br />