Laserfiche WebLink
UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK NOV 15 2016 <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> erf <br /> Lu <br /> TYPE OF ACTION ® L NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACOAPJ�NT 400. <br /> (Check one item only) El 3.RENEWAL PERMIT LtII CC <br /> ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION a p 2b l5b <br /> TOTAL NUMBER OF USTs AT FACILITY 404- FACILITY ID# _ t <br /> 2(20k gal, 12k/8k gal split) (Agency Use Only) <br /> BUSINESS NAME(Same as FACMUY NA or DBA-Doing Business As) 3. <br /> AG-f F(11G-L I ifC, <br /> BUSINESS SITE ADDRESS 103. CITY 10`1. <br /> 1490 SOUTH MAIN STREET MANTECA <br /> FACILITY TYPE ® I.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 40 Is the facility located on Indian Reservation or 405. <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑Yes ®No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408. <br /> (ANNIE)GURPREET SANDHU 925 785-2000 <br /> MAILING ADDRESS 409. <br /> 2823 E.SUGARHILL TERRACE <br /> CITY 410 1 STATE 411. ZIP CODE 412. <br /> DUBLIN CA 94568 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1 PHONE 428-2 <br /> SAME AS PROPERTY OWNER <br /> MAILING ADDRESS 428-3 <br /> CITY 428-0 I STATE 428-5 ZIP CODE 428-6 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> SAME AS PROPERTY OWNER ) - <br /> MAILING ADDRESS 416. <br /> CITY 417 1 STATE 418. ZIP CODE 419_ <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 /> TY(TK)HQ 44- Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421 <br /> VI.PERMIT HOLDER INFORMATION <br /> g g ® I.FACILITY OWNER [14.TANK OPERATOR 423 <br /> Issue permit an send legal notifications and mailings to: <br /> ❑ 3.TANK OWNER ❑ S.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) 406. <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I certif the informati provided herein istrue,accurate,and in full compliance with legal requirements. <br /> APPLICANT SIGNATURE DATE 424 PHONE 425. <br /> 1( (5116 925 785-2000 <br /> APPLICANT NAMEmt) 426. APPLICANT TITLE 427 <br /> (ANNIE)GURPREET SANDHU fP�ESf j1EA/T <br /> UPCF UST-A Rev.(12/2007) <br />