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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK J' <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> !. (Oneian�per facility) <br /> TYPE OF ACTION ❑ 1.NEW PERMIT ® 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400. <br /> (Check one item only) [:19.TRANSFER PERMIT <br /> El 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404. FACILITYID# <br /> 1 (Agency Use Onl <br /> BUSINESS NAME(Bsmess FAC=NA mDBA-Doing Busmen Aa) 3. <br /> California Highway Patrol#265 <br /> BUSINESS SITE ADDRESS 103. CITY 1a4. <br /> 3330 North Ad Art Road Stockton <br /> FACILITY TYPE ® 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 903' Is the facility located on Indian Reservation or 405' <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑Yes ❑No <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 408. <br /> California Highway Patrol (916) 843-3806 <br /> MARLING ADDRESS 409. <br /> 3330 North Ad Art Road <br /> CITY 410. 1 STATE 411. ZIP CODE 412. <br /> Stockton CA 95215 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. PHONE 42s-2 <br /> California Highway Patrol (916) 843-3806 <br /> MAU-ING ADDRESS 428-3 <br /> 3330 North Ad Art Road <br /> CITY 4284 STATE 429-5 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. 1 STATE 418. ZIP CODE 419. <br /> Sacramento CA 94298 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY Z 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- 101312101612Call 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)Beth DEPaola 406. <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I certq that the informs ' rovided herein is true accurate and in full compliance with legal requirements. <br /> APPLICANT SIGNATURE Z,5,1 DATE 424, PHONE 425. <br /> 7/12/2017 (805) 929-8944 ext 1002 <br /> APPLICANT NAME(print) 426. 1 APPLICANT TITLE 427 <br /> Glenn Paredes Project Coordinator <br /> UPCF UST-A Rev.(12/200D <br />