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IED PROGRAM CONSOLIDATED FO: <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION X 1.NEW PERMIT <br /> (Check one item only) El 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE aoo. <br /> ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404. FACILITY m# 1 <br /> 2 (Agency Use Only) <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) <br /> French Camp 76 Express <br /> BUSINESS SITE ADDRESS 103. CITY 104 <br /> 5777 S. French Camp Road Stockton <br /> FACILITY TYPE x 1.MOTOR VEHICLE FUELING403 <br /> ❑ 2.FUEL DISTRIBUTION Is the facility located on Indian Reservation or 405 <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑Yes x No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 40T209-983-4781 <br /> HONE 408, <br /> Darashan Singh <br /> MAILING ADDRESS <br /> 409, <br /> 5777 S. French Camp Road <br /> CITY 410. 1 STATE 411. <br /> ZIP CODE 412. <br /> Stockton CA 95206 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME <br /> 7=;�� azs-z <br /> Darashan-Singh <br /> MAILING ADDRESS 428-3 <br /> 5777 S. French Camp Road <br /> CITY 428-44 1 STATE 428-5 <br /> ZIP CODE. 428-6 <br /> Stockton CA 95200 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME ala. PHONE 415, <br /> Darashan Singh 209-983-4781 <br /> MAILING ADDRESS 416. <br /> 5777 S. French Camp Road <br /> CITY 417. STATE 418. ZIP CODE 419. <br /> Stockton CA 95206 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY azo. <br /> ❑ 7.FEDERAL AGENCY X 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 1 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: ❑ L FACILITY OWNER ❑ 4.TANK OPERATOR 423 <br /> X 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 /> APPLICAN URE DATE 424,. PHONE 425. <br /> - 0 S (916) 373-1166 <br /> APPLICANT NAME print) 426. APPLICANT TITLE 427 <br /> Dulcinea Webb Compliance Manager <br /> UPCF UST-A Rev.(12/2007) <br />