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t� o' <br /> .,t IFIED PROGRAM CONSOLIDATED FO1kTR Fib o <br /> UNDERGROUND STORAGE TANK ja 4- Q1 D <br /> OPERATING PERMIT APPLICATION- FACILITY INFORMATIO <br /> (One form per facility) <br /> TYPE OF ACTION ❑ 1.NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 4W <br /> (Check,,item wdo ® ; RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404. 1 FACILITY IDN _ _ 1. <br /> (Agency Use Only) l <br /> BUSINESS NAME(Some as Facility Name-r DBA-Doing Business As) 3. <br /> Sprint Stockton Switch <br /> BUSINESS SITE ADDRESS 103. CITY w4. <br /> 3807 Coronado Ave. 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? ❑ 1.Yes ® 2.No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407, 1 PHONE 4n8. <br /> Sprint United Management Co. (877) 347-4457 <br /> MAILING ADDRESS 409 <br /> P.O. Box 7994 <br /> CITY 410, STATE 411, <br /> ZIP COME 412. <br /> Shawnee Mission KS 66207-0994 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 429-1. PHONE 428-2 <br /> Sprint United Management Co. (877) 347-4457 <br /> MAILING ADDRESS 429 s <br /> P.O. Box 7994 <br /> CITY 4294. STATE 428-5. <br /> ZIP CODE 428 6. <br /> Shawnee Mission KS 66207-0994 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> Sprint United Management Co. (877) 347-4457 <br /> MAILING ADDRESS d16, <br /> 11, P.O. Box 7994 <br /> 'N CITY 417. STATE 418. ZIP CODE 419, <br /> Shawnee Mission KS 66207-0994 <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- 4 1 2 8 1 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 ❑ 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 /> VH.APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that the information provided herein is true,accurate,and in full com fiance wt le-' requirements. <br /> APPLICANT SIGNATURE DATE 4z4. PHONE„ 425. <br /> 1/25/2010 (650) 375-2019 <br /> APPLICANT NAME(print) 4za. APPLICANT TITLE 427 <br /> Pete Wang EHS S ecialist <br /> UPCF UST-A Rev.(12/2007)-1/2 www.unidocs.org a, <br /> .4 <br />