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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 [15.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400. <br /> (Check one item only) 1193.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404' 1 FACILITY ID# FIAT- <br /> _ _ 1 <br /> S (Agency Use Only) IT 6 <br /> BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3' <br /> Mk-(hl STIP ET M-W " PM E-NTf:j_PA1SC LLC, <br /> BUSINESS SITE ADDRESS 103. CITY 104. <br /> \\bo S. Mhlhl ST(Lc2T fAA-►TtC4N , CA -1533 -4 <br /> 405. <br /> FACILITY TYPE 1.MOTOR VEHICLE FUELING El 2.FUEL DISTRIBUTION Is the facility located on Indian Reservation or <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑ 1.Yes 92.No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 408. <br /> 3'ESKUL eNTEXPf,1Z LLQ; 6 3y-10 <br /> 409, <br /> MAILING ADDRESS <br /> 6-1 t39-uEs AWE: <br /> CITY ato. STATE alt. ZIP CODE 41= <br /> r t-emiIu -T 4 114S3,. <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. PHONE 428.2. <br /> MA-(N STP-E,ET A4j-o AwOm - LLC, ( Zi3q 'bLS-(61Vj <br /> 428-3. <br /> MAILING ADDRESS <br /> I� p� S-- MA-IIJ Stl2E�T <br /> CITY 4294. 1 STATE 428-5. ZIP CODE 428-6. <br /> A TE CA C--Pr `t 533 I <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> M k1N STPLE6T / -CC S i;NTcF-P RISE LLC. ( ILOQ <br /> 416. <br /> MAILING ADDRESS <br /> k\ 00 S. N1 1,1 S T -LET <br /> CITY 417. F§TATE ats. ZIP CODE als. <br /> M PrNZtct CIN `1533] <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY .)2(8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 4- sI I ( Call the State Board of Equalization,Fuel Tax Division,if there are questions. 12' <br /> VI.PERMIT HOLDER INFORMATION <br /> 423. <br /> Issue permit and send legal notifications and mailings to: ❑ 1.FACILITY OWNER [j4.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 <br /> CERTIFICATION: I certify that the information provided herein is true,accurate,and in full com fiance with le al requirements. <br /> APPLICANT SIG DATE 424 PHONE 425. <br /> 3 2o�c� $Ioq X25-6��4 <br /> APPLICANT NAME(print) 426. APPLICANT TITLE 427 <br /> KOLDEEP C - SNWA4A (MCM(3Efo LLL <br /> UPCF UST-A Rev.(12/2007)-1/2 www.unidocs.org <br />