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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUNDSTORAGETANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION ❑ L 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 414. FACILITY ID# Z 11 <br /> 1 (Agency Use Onl <br /> BUSINESS NAME(same as FACILITY NAME omen-nom,Buameas A:) <br /> California Highway Patrol#265ENV:-- <br /> BUSINESS <br /> P `/;BUSINESS SITE ADDRESS 103. CITY _ 104 <br /> 3330 North Ad Art Road Stockton <br /> FACILITY TYPE ® 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403 Is the facility located on Indian Reservation or 405' <br /> ❑ 3.FARM (1 4.PROCESSOR ❑ 6.OTHER Trust lands? Cl Yes ❑No <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 001 PHONE 408. <br /> California Highway Patrol 916) 843-3806 <br /> MAILING ADDRESS 409. <br /> 3330 North Ad Art Road <br /> CITY 410. STATE 411. 1 ZIP CODE 412. <br /> Stockton CA 95215 <br /> M. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. PHONE 4284 <br /> California Highway Patrol (916) 843-3806 <br /> MAILING ADDRESS 4283 <br /> 3330 North Ad Art Road <br /> CITY 4284 1 STATE 428-5 1 ZIP CODE 428-6 <br /> Stockton CA 95215 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> California Highway Patrol (916) 843-3806 <br /> MAILING ADDRESS 416. <br /> PO Box 942898 <br /> CITY 417. STATE 418. 1 ZIP CODE 419, <br /> Sacramento CA 94298 <br /> OWNERTYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ® 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY ❑ S.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 1 0 1 3 1 2 1 0 1 6 1 2 1 Call the State Board of Equalization,Fuel Tax Division,if there we 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)Beth DEPaola 406. <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I cern that the informMUm.Rrovided herein is true accurate and in full compliance with legal requirements. <br /> APPLICANT SIGNATURE DATE 424. PHONE 425. <br /> 7/12/2017 805) 929-8944 ext 1002 <br /> APPLICANT NAME(print) 426. APPLICANTTITLE 427 <br /> Glenn Paredes Project Coordinator <br /> UPCF UST-A Rev.(12/2007) <br />