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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION—FACILITY INFORMATION <br /> (One form Per facility) it <br /> TYPE OF ACTION ❑ I.NEW PERMIT El 5.CHANGE OF INFORMATION ® 7.PERMANENT FACILITY CLOSURE 10e <br /> (Check ane ilem anly) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> L FACILITY INFORMATION <br /> TOTAL NUMBER OF USTS AT FACILITY 4", 1 FACILITY IDM _ _ /) 1 <br /> 1 A en Use On! O� 3 <br /> BUSINESS NAME(Same n PACIW NAME a DDA-Doing Rusin.M) <br /> CALTRANS Highway 26 Right of Way,State of California <br /> BUSINESS SITE ADDRESS 103 CITY <br /> N.E.comer of 19107 East Hi wa 26(Caltrans Right of We Linden <br /> FACILITY TYPE ® I.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION ' Is the facility located on Indian Reservation or <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER <br /> Trust lends'? ❑Yes ®No i <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407, PHONE 408. <br /> State of California(Caltrans) 559)445-6378 <br /> aoa <br /> MAILING ADDRESS <br /> 855 M Street,Suite 200 <br /> CITY 410. STATE 411 ZIP CODE u2. <br /> Fresno CA 93721 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 42&1. 1 PHONE 42&2 <br /> Unknown <br /> 42&l <br /> MAILING ADDRESS <br /> CITY <br /> 4234 STATE 428-5 ZIP CODE 428-6 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE W <br /> State of California(Caltrans) (559)445-6378 <br /> MAILING ADDRESS 41e. •� <br /> 855 M Street,Suite 200 <br /> CITY 417. 1 STATE au. ZIP CODE 419 <br /> Fresno CA 93721 <br /> OWNER TYPE: ❑ 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 /> an <br /> TY(TK)HQ 44- Cell the Stale Boats of Equalization,Fuel Tax Division,if[here are questions. <br /> VI.PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: ® L FACILITY OWNER ❑ 4.TANK OPERATOR <br /> an <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only)Clem Goewert <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: 1 cern that the information provided herein is true,accurate and in full corn liance with I al requirements. <br /> APPLICANTSIGNATURE DATE 4:4. PHONE 42° <br /> 10/14/2014 916) 852-9118 <br /> 422 <br /> APPLICANT NAM nnt) 436. APPLICANT TITI,F. <br /> Bob M. Kimball RME,Authorized A ent for Caltrans <br /> UPCF UST-A Rev.(12/2007) <br />