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UNIVITD PROGRAM CONSOL10DATED FORM <br /> UNDERGROUND STORAGE TANK t J`; <br /> OPERATING PERMIT APPLICATION—FACILITY INFORMAnON <br /> (Ona form per facility) <br /> TYPE OP ACTION ❑ L NEW PERMIT 0 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE400. <br /> (Check one item only) ❑ 3,RENEWAL PERMIT p 6,TEMPORARY FACILrrY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I .FACKtrY JNA 0' tMATZON <br /> TOTAI,NUMBER OP LISTS AT FACILITY PACILITY M II <br /> 3 (Ar�„Cy use only) � � e1 <br /> 3. <br /> BUS IW.SS NAME(Some n,VACn rrY N&M or DI<A-Dning nosinam As) <br /> Thornton 76 <br /> HUSMESS SITES ADDRESS 103, CITY j01 <br /> 8606 Thornton Road Stockton <br /> FACILITY TYPE ® 1.MOTOR VP_I,IJCT R FUELING © 2•FUEL DISTRIBUTTON 703' Is the facility locatod on Indian Reservation or 405. <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6,OTHER Trust lands? ❑Yes ®No <br /> U. PROPI�RTY OWNER INFORMATION <br /> PROPERTY OWNWZ NAME 107, 1 PFIONF ^o$ <br /> wasq -Ea f T- 1209-478••8959 <br /> Mn II,TNG}ADDRESS "09. <br /> 10944 Ramming Star Lane _ <br /> CTT4' ^10. STATIi 411 1 ZIP CODE <br /> Stockton CA _ 95209 _ <br /> 'X ANIC'OPERATOI AVkORMA BION <br /> TANK OPERATOR NAME 12N 1. PHONE 428.2 <br /> Rai Gas 209-478-8959 <br /> MAILING}ADDRESS 429-3 <br /> 8606 Thornton Road <br /> CITY 42A7STATE. 4ffCs I ZIP CODE 45-A <br /> Stockton CA 95209 <br /> .. a IV.:::TANK.OWNXt ORMATION:, <br /> TANK OWNERNAME 414. P110NG ^u. <br /> R&ASAGAvg2fcpF" ; "g ,�,�, L 1209-478-8959 <br /> MAILING ADDR2_S 41G <br /> 10944 Ramming Star Lane <br /> CITY 417, STATE 419, 7iP CODL 419- <br /> Stockton CA 95209 <br /> OWNER TYPE: C7 4.LOCAL AOENCY/DISTRIGT (3 5.COUNTY AOGNCY ❑ 6,ST'ATr AGENCY 421. <br /> Ll 7,FEDERAL AGENCY ISI R.NON-GOVERNMENT <br /> V. I3OA-RD-OF EQUALIZATION UST STORAGE.FrE ACCOUNT NUMBER <br /> TY CM)-HQ 44- ^? ( Call the Stats Board of Equalization,Fuet Tax Division.if tflcre arc quc5tions. 721 <br /> VX.'x'rlt�1l7'�HOLDER INFORMATION �. <br /> Issue permit And Send legal notifications and mailings to: El 1,T ACTLlTY OWNER ❑ 4.TANK OPERATOR 423 <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE;(Roduired For Public Agencies Only) One, <br /> VII.APPLICANT STGNATVRE <br /> CERTIFICATION! I certify that the information provided herein is no,accurate,and in full compliance with legal requirements. <br /> APPLICANT SIONATUR DATE .� 124 FT1014E 725. <br /> e2 fav 209478-8959 <br /> APPI.iCAN'C NAME(print) 42e. APPLICANT TiTt,.? 4;T <br /> Amar'it Rai 6 <br /> V)7CF UST-A Rev.(17./2007) <br />