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9 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION -FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION ❑ 1.NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 40°. <br /> (Check one item only) Z 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404, FACILITY ID# 1. <br /> 1 (Agency Use Only) <br /> BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3. <br /> Food Mark Gasoline <br /> BUSINESS SITE ADDRESS 103. CITY 104. <br /> 2185 E. Fremont 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 Z 2.No <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 401. PHONE /S �2 / 7 ! 408. <br /> Jojinder Lal {@Nr98:7 &"5 <br /> MAILING ADDRESS 409. <br /> 840 Dupont Drive <br /> CITY 410. STATE all. ZIP CODE 412. <br /> Stockton CA 95210-2018 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. PHONE /� , _ y / ?Q ,7 `429-2 <br /> Jo inder Lal (299)-95:7-8195 <br /> [[ / / 0 <br /> MAILING ADDRESS 428-3. <br /> 840 Dupont Drive <br /> CITY 428-4. STATE 428-5• ZIP CODE 429-6. <br /> Stockton CA 95210-2018 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE s_ L/ I q n j 415. <br /> Joinder Lal (29 7 <br /> MAILING ADDRESS 416. <br /> 840 Dupont Drive <br /> CITY 417. STATE 418. ZIP CODE 419. <br /> Stockton CA 95210-2018 <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 UK)HQ 44- 1 FT 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: Z 1.FACILITY OWNER Z 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 SIGNATURE DATE aza. PHONE /)s /'79�425. <br /> I <br /> APPLICANT NMvE(priniT 426• APPLICANT TITLE an <br /> Jojinder Lal Operator/Owner <br /> UPCF UST-A Rev.(12/200)-1/2 www.unidocs.org <br />