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RECEIVED 5 2013 UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK ENVIRONMENL- OPERATING PERMIT APPLICATION-FACILITY INFORMATIOt} *LTH DEPART ME (One form per facility) TYPE OF ACTION ❑ 1,NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400, (Check one item,only) 3 RFNEWAZ,PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 4.TRANSFER PERMIT . >..,.. ;. .....• ,' �L;:FACILITY.TIYFORNIATYON.--:•... ,... ::•`;; ;: ;.<:.;•:;::...;, ;;•. .-;: TOTAL NUMBER OF USTs AT FACILITY 4p4, FACILITY ID# ^ t 1. (Agency Use Only) �k 'Q D lo 1 Q L BUSINESS NAME(Swe as FACa=NAME or DBA-Doing 8usioen As) 3' BUSINESS SITE ADDRESS 103. CITY 104• 39 6- yoSe--6te PAA G Mq.h�P- 3 FACILITY TYPE 0 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403. is the facility located on Indian Reservation or 405, ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑Yes No IL PROPER'T'Y.OWNER INFORMATION ,. PROPERTY OWNER NAME 407. PHONE 408. qe,, AOS Aocr 65-- 311 Li MAILING ADDRESS ao9. p0, ion 1 � � 7 CITY 410. STATE 411. ZIP CODE 412• Si o C-V'rro N `l III. I'ANx.OP)EAA MA INFORMATION. TANK OPERATOR NAME 429.1. PHONE 4z8 z FA,5 i All --P /6 ( A-o9 ) ?z3 - ,3'1 6 a MAILING ADDRESS 426.3 l 3`i`~I Fi' as;r.w�4r� ►A J� . CITY 428" STATE 428-5 1 ZIP CODE 426.6 ✓�Gl��e.Ccti �i't S 36 IV.` ,TANK OWNER XNFORMAxXON,. TANK OWNER NAME 414, PHONE au. MAILING ADDRESS 416. CITY 417. STATE ale. ZIP CODE 419. OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6,STATE AGENCY 420. ❑ 7.FEDERAL AGENCY ❑ S.NON-GOVERNMENT K BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER. TY(TI{)HQ 44- Call the State Board of Equalization,fuel Tax Division,if there are questions. 42). VI.PERMIT HOLDER.INFORAU T IOLV Issue permit and send legal notifications and mailings to: ❑ 1,FACILITY OWNER ❑ 4.TANK OPERATOR 423 ❑ 3.TANK OWNER ❑ 5,FACILITY OPERATOR SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) 406. VII:APPLICANT SIGNATURE CERTIFICATION I certifv that the information provided herein is true,accurate and inful{com lienee with legal re uiremcnt6• -: APPLICANT SIGN DATE 420• PI•IONE t..' "au $ 1 (z5C 52-3 -ZLI 9-0 APPLICANT (print) 426. APPLICANT TITLE 5427 tA I A 00 H1� CA9 wt Y- y' UPCF•UST-A Rev.(I2n007) �.•..