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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUNDSTORAGETANK <br /> OPERATING PERMIT APPLICATION -FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION ❑ 1.NEW PERMIT [15.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE <br /> (Check one nem only) ® 3 RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ® 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> t. <br /> TOTAL NUMBER OF USTs AT FACILITY 404' FACILITY m H _ - <br /> 1 (Agency Use Only) <br /> 3. <br /> BUSINESS NAME(Same as Facally Name or DBA-Doing Business As) <br /> BUSINEM Mini Mart <br /> SS SITE ADDRESS <br /> 1756 Wilson Way Stockton <br /> 4m. aos. <br /> FACILITY TYPE ® 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION -Ifs the frust acility located <br /> ted es Indi R2.N ervation or <br /> El 3.FARM 4.PROCESSOR ❑ 6.OTHER <br /> II, PROPERTY OWNER INFORMATION <br /> PROPERTY OWN ER NAME 407. PHONE 408' <br /> Lal Jojinder 209 941-2264 <br /> 409. <br /> MAILING ADDRESS <br /> 1756 Wilson Way <br /> all. ZIP CODE 412. <br /> CITY <br /> ata STATE <br /> Stockton CA 95205 <br /> IM TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 429-1. PHONE azs-z. <br /> Ram Rattan (209) 941-2264 <br /> 428-a. <br /> MAILING ADDRESS <br /> 1756 Wilson Way <br /> CITY <br /> 4294. STATE azs-5. ZIP CODE 42" <br /> Stockton CA 95205 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> Lal Jojinder (209) 941-2264 <br /> 416. <br /> MAILING ADDRESS <br /> 1756 Wilson Way <br /> CITY 412 STATE 419. ZIP CODE 419. <br /> Stockton CA 95205 <br /> OWNERTYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 4za <br /> ❑ 7.FF:DFRAL AGENCY ❑ R.NON-GOVF.RNMF:NT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- <br /> Call the State Board of Equalization,Fuel Tax Division,if there are questions. ay. <br /> VL PERMIT HOLDER INFORMATION <br /> 42i. <br /> Issue permit and send legal notifications and mailings to: ❑ 1.FACILITY OWNER Z 4.TANK OPERATOR �� <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR\Z <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Requiredfor Public Agencies Only) e06' <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that the information provided herein is true,accurate,and in full compliance with legal re uire <br /> APPLICANT SIGNATURE 'w DATE 4z4. PHONE 425' <br /> 7/8/2009 209 941-2964 <br /> APPLICANT NAME(print) 426. APPLICANT TITLE an <br /> Ram Rattan Manage Oerator <br /> UPCF UST-A Rev.(12/2007).112 www•4mldoca.°rB <br />