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UNIFIED PROGRAM CONSOLIDATED FORM 5 l� I <br /> UNDERGROUND STORAGE TANK l <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 400. <br /> (Check one item only) ❑ 3.RENEWAL PERMIT <br /> ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404, FACILITY ID# _ _ // 1 <br /> 3 (Agency Use Only) Lt <br /> BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3• <br /> Pacific Gas and Electric Company, Stockton Service Center <br /> BUSINESS SITE ADDRESS 103 CITY 104, <br /> 4040 West Lane 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 ® 2.No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407, PHONE 408, <br /> Des Bell 415) 973-4545 <br /> MAILING ADDRESS 409. <br /> 77 Beale Street <br /> CITY 410. STATE 411. ZIP CODE 412. <br /> San Francisco CA 94105 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. PHONE 428-2. <br /> Michelle Le (209) 602-7038 <br /> MAILING ADDRESS 428-3_ <br /> PO Box K <br /> Cil) 4284. STATE 428-5. ZIP CODE 428-6. <br /> Victor CA 95253 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> Des Bell (415) 973-4545 <br /> MAILING ADDRESS 416. <br /> 77 Beale Street <br /> CITY 417. 1 STATE 418. ZIP CODE 419. <br /> San Francisco CA 94105 <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(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 /> 423. <br /> Issue permit and send legal notifications and mailings to: ❑ 1.FACILITY OWNER ® 4.TANK OPERATOR - <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required for Public Agencies Only) 406 <br /> VII. APPLICANT SIGNATURE i <br /> CERTIFICA ION: I c rtif that the information provided herein is true,accurate,and in full com liance with legal re uirementsd:- <br /> APP IC T SNA DATE 424. PHONE 425 <br /> 7,4 11/24/2008 (209) 602-7038 . <br /> AP AN AME(prin 426. APPLICANT TITLE <br /> Michelle Le Environmental Specialist <br /> UPCF UST-A Rev.(12/2007)-1/2 www.unidocs.org <br />