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i.aN �1 <br /> ii . IED PROGRAM CONSOLIDATED FO 111 2rp/�9'19 ' <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION- FACILITY INFORMATION <br /> (One form per facility) <br /> 400. <br /> TYPE OF ACTION ❑ 1.NEW PERMIT ® 5.CHANGE OF INFORMATION ❑ T PERMANENT FACILITY CLOSURE <br /> (Check one item only) ❑ 3 RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> 1: <br /> TOTAL NUMBER OF US IS AT FACILITY 404. FACILITY ID# <br /> 4 1 (Agency Use Only) - - <br /> 3. <br /> BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) <br /> Tower Market#104 Ina. CITY 104. <br /> BUSINESS SITE ADDRESS Lathro , CA 95330 <br /> 192 Lathrop Rd. 403 405. <br /> FACILITY TYPE ® 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION Trust lands?is the y❑localY es on Ia® 2.No dian Reservation or <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER f :,,... <br /> IL PROPERTY OWNER INFORMATION <br /> 4o7- PHONE .:. 408.,. <br /> PROPERTY OWNER NAME <br /> Tower Energy Group 310 538-8000 <br /> 409. <br /> MAILING ADDRESS <br /> 1983 W. 190th St 41t. z>PcoDE 412. <br /> CITY 410. STATE <br /> Torrance CA 90504 <br /> L TANK OPERATOR INFORMATION <br /> 428-1. PHONE 428-2. <br /> TANKOPERATOR NAME <br /> Tower Energy Group (916) 285-7402 <br /> 428-3. <br /> MAILING ADDRESS <br /> 20 Goldenland Court 4284. 1 STATE 428'5. ZIP CODE 4285. <br /> CITY <br /> Sacramento CA 95834 <br /> "IV' TANK OWNER INFORMATION <br /> 4K PHONE 415. <br /> TANKOWNERNAME <br /> Tower Ener Group (310) 538-8000 <br /> 416. <br /> MAILING ADDRESS <br /> 1983 W. 190' St. 419. <br /> CITY 417. 1 STATE 418. 1 ZiFCODE <br /> Torrance CA 90504 <br /> 420. <br /> OWNER TYPE: [14.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY <br /> ❑ 7.FEDERAL AGENCY ❑ 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> 4>r <br /> TY(TK)HQ 44- 1 318 14 14 1 0 1 Call the State Board of Equalization,Fuel Tax Division,if there are questions. <br /> VI PERMIT HOLDER INFORMATION <br /> 23 <br /> Issue permit and send legal notifications and mailings to: ❑ 1.FACILITY OWNER ® 4.TANK OPERATOR <br /> ❑ 3.TANKOWNER ❑ 5.FACILITY OPERATOR <br /> 406. <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required for Pu6[ic Agencies Only) .a„� <br /> VII. APPLICANT SIGNATURE :. <br /> CERTIFICATION: I certif at the information provided herein is true accurate and in full conlli ance with Ie at re mr ents. 4zs <br /> APPIJQVT S NATU DATE PHONE <br /> // '.. <br /> 8/22/2009 916 285- 3.42 <br /> APPLICANT NAME(print) <br /> 426. APPLICANT TITLE 4n <br /> Paul Chevalier Maintenance Manager <br /> UPCF UST-A Rev.(1212007)-1/2 www.unidoes.org <br />