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9 <br /> r <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <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 <br /> (CAeck ove uem o,Jyj ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILfrY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY904' FACILTfY R)# 1. <br /> 11 <br /> 3 (Agency U orgy) - - 0 1 7 8 1 9 <br /> BUSINESS NAME(Same as Forcibly Name or DBA-Doing Business As) 3. <br /> GASSPECS, INC. dba GREAT AMERICAN GAS & CAR WASH <br /> BUSINESS SITE ADDRESS lm. 1 CITY 104 <br /> 2115 W. Yosemite Ave. Manteca <br /> FACILITY TYPE ® 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRBUTION 903- Is the facility located on Indian Reservation or aos. <br /> ❑ 3.FARM ❑ 4.PROCESSOR 0 6.OTHER Trust lands? ❑ 1.Yes ® 2.No <br /> IL PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 'Kn PHONE 408 <br /> GASSPECS, INC. (209)823-5654 <br /> MAILING ADDRESS 409. <br /> 1883 ROCHESTER <br /> CITY 410 STATE 411. ZIP CODE 412 <br /> TRACY CA 95377 <br /> III. TANK OPERATOR INFORMATION <br /> TANKOPERATORNAME 42a1. PHONE 42 2. <br /> GASSPECS, INC. (209) 823-5654 <br /> MAILING ADDRESS 4283, <br /> 1883 ROCHESTER <br /> CITY 428.x. STATE Q8-5 I ZIP CODE aza-6 <br /> TRACY CA 95377 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME ale PHONE 418 <br /> GASSPECS, INC. (209)823-5654 <br /> MAILING ADDRESS 416. <br /> 1883 ROCHESTER <br /> CITY 417. 1 STATE 418. Z1 CODE 419 <br /> TRACY CA 95377 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 4m. <br /> ❑ 7.FEDERAL AGENCY M 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY H 44 Call the State Board of Equalization,Fuel Tax Division, 421. <br /> Q Eq on, on,ifthae are questions. <br /> VI. PERMIT HOLDER INFORMATION <br /> Issue it and send 1 notifications and mailin to: ❑ 1.FACILITY OWNER 423. <br /> Pahl legal gs ❑ 4.TANK OPERATOR <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Requiredjor Public Agencies Only) 406. <br /> VII.APPLICANT SIGNATURE <br /> CERTMCATION: I certify that the information purravided herein is true accurate and in full compliance with legal uimments. <br /> APPLICANT SIGNATURE DATE 424 PHONE 425, <br /> APPLICANT NAME(print) 426. 209 823-5654 <br /> APPLICANT TITLE 427 <br /> SYED K. AIVOED VICE PRESIDENT <br /> UPCF UST-A Rev.(12!2047)-1/2 www.ualdocs.org <br />