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IVSD PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facility) <br /> 400 <br /> TYPE OF ACTION ❑ 1.NEW PERMIT ® 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE <br /> (Check one item only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404 FACILITY ID 0 _ t <br /> 2 (Agency Use Only) I Ll <br /> BUSINESS NAME(same as FACILITY NAME or DBA-Doing Business As) <br /> Yosemite 76 #255417 <br /> BUSINESS SITE ADDRESS 103 CITY 1°4. <br /> 1700 East Yosemite Avenue Manteca <br /> 405. <br /> FACILITY TYPE ® 1.MOTOR VEHICLE FUELING [12.FUEL DISTRIBUTION 403 is the facility located on Indian Reservation or <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑Yes ®No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE <br /> Statewide Petroleum, Inc. 209-823-7676 / <br /> 409. <br /> MAILING ADDRESS <br /> 1700 East Yosemite Avenue <br /> CITY 410. 1 STATE 411 Zip CODE 412. <br /> Manteca CA 95336 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. 1 PHONE 428-2 <br /> Statewide Petroleum, Inc.-Sunny Bhullar 209-823-7676 <br /> 428-3 <br /> MAILING ADDRESS <br /> 1700 East Yosemite Avenue <br /> CITY 428-4 STATE 428-5 ZIP CODE 428-6 <br /> Manteca CA 95336 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415 <br /> Statewide Petroleum, Inc. 209-823-7676 <br /> 416. <br /> MAILING ADDRESS <br /> 1700 East Yosemite Avenue <br /> CITY 417 STATE ala. ZIP CODE 419 <br /> Manteca CA 95336 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420 <br /> ❑ 7.FEDERAL AGENCY ® 8.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 /> 423 <br /> Issue permit and send legal notifications and mailings to: ® 1.FACILITY OWNER ❑ 4.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 compliance with le al requirementsF". <br /> APPLICANT SIGNATURE DATE 424. PHONE " 425 <br /> �_ ) - 1 9.- 11 209-823-7676 <br /> APPLICANT NAME(print) 4'-6 APPLICANT TITLE 7 <br /> SunnyBhullar Owner � � µ� <br /> UPCF UST-B-1/1 <br /> �iii^i:SZgatl <br />