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06/04/2009 00:27 9252920074 GDF_SOLUTIONS FAX PAGE 11/15 <br /> cm>• <br /> UNIFIED PROGRAM CONSOLIDATED FORM C7�! <br /> UNDERGROUND STORAGE TANK �./p��r <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION '�( ( p� <br /> (One form per facility) <br /> TYPE OF ACTION ❑ 1.NEW PERMIT ❑ S.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400. <br /> (Check one item only) 14 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404, FACILITY M 4 Wq1,311L 2 (Agency Use Only) 1 -1- 1- 1 <br /> 1 - 1 <br /> BUSINESS NAME(Sarna as:Facility) arne or DBA-.Doing Bwtindss As) 3• <br /> Country Club 76 <br /> BUSINESS SITE ADDRESS 103. CITY 104. <br /> 2575 Country Club Blvd Stockton <br /> FACILITY TYPE ® I.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403' Is the facility located on Indiana Reservation or 40 <br /> 5, <br /> ❑ 3.FARM ❑ 4.PROCESSOR, ❑ 6.OTHER Trust lands? ❑ 1.Yes Z 2.No <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407• PHONE Aon. <br /> CA Fuel Supply 925) 979-0467 <br /> MAILING ADDRESS 408. <br /> 587 Y nacio Valley Road <br /> CITYsto. STATE 411, ZIP CODE 412. <br /> Walnut Creek Ca 94596 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. PHONE 429-2. <br /> CA Fuel Supply 1 (925) 979-0467 <br /> MAILING ADDRESS 42M, <br /> 587 Ygnacio Valley Road <br /> CITY 4=9-4• STATE 429-5. 1 ZIP CODE 428-6. <br /> Walnut Creek I Ca 94596 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> CA Fuel Suply 1 (925) 979-0467 <br /> MAILING ADDRESS 416. <br /> 587 Y nacio Valley Road <br /> CITY 417 STATE 418. 1 ZIP CODE 1119. <br /> Walnut Creek I Ca 94596 <br /> OWNER TYPE: ❑ 4.LOCAL,A,GF.NCY/DISTRICT ❑ 5,COUNTY AGENCY ❑ 6.STATE AGENCY azo. <br /> 0 7.FEDERAL AGENCY Z 8.NON-GOVERNMENT , <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK,)HQ 44- 0 4 . 5 6 113 '[ Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421' <br /> VI. PERMIT MOLDER INFORMATION . <br /> Issue permit and send legal nodficatiorls and mailings to: ® I.FACILITY OWNER El 4.4,TAMC OPERATOR �I <br /> ❑ 3.TANK OWNER ❑ 5,FACILITY OPERATOR <br /> SUPERVISOR OF DIVTSTON,SECTION,OR OFFICE(Requiredfor Public Agencles Only) 406. <br /> VII.APPLICANT SIGNATURE <br /> CERTI>FIC ce at th ' ormation provided herein is true,accurate,and in full compliance with! al requirements. <br /> APPLICANT iQ AT DATE 424 PRONE 425, <br /> 5/6/2009 925 989-8223 <br /> APPLICANT NAME(print) 426. APPLICANT TMP- 41*7 <br /> David Hinds Sales Manager <br /> UPCF UST-A Rev.(12/2067)- 1/2 www.vaidoes.org <br />