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UNIFIED PROGRAM CONSOLIDATED FORM <br />UNDERGROUND STORAGE TANK <br />OPERATING PERMIT APPLICATION -- FACILITY INFORMATION <br />(One form per facility) <br />aoo. <br />TYPE OF ACTACTION❑ 1. NEIN PERMIT [15. CHANGE OF INFORMATION El7. PERMANEN-I' FACILITY CLOSURE <br />(Check nne item ail)) ® 3. RENEWAL. PERMIT ❑ 6. TEN4PORARY FACILITY CLOSURE ❑ 9. TRANSFER PERMIT <br />L FACILITY INFORMATION <br />TOTAL_ NUMBER OF USTs AT FACILITY 404 FACILI'T'Y ID # <br />_ <br />Tt <br />;3 (Agency Use Only) <br />BUSINESS NAME (Same as FacilityNmne or DBA — Doing Business As) t <br />Flyers #487 <br />BUSINESS SITE ADDRESS Ip3. <br />CITY 104' <br />983 Moffat Blvd <br />Manteca <br />ao1. <br />FACILITY TYPE ® L NIOTOR VEHICLE FUELING [12. FUEL DIS'T'RIBUTION <br />aos. <br />Is the facility located on Indian Reservation or <br />❑ 3. FARM ❑ 4. PROCESSOR ❑ 6. OTHER <br />"frust lands? ❑ 1. Yes ® 2. No <br />II. PROPERTY OWNER INFORMATION <br />PROPERTY OWNER NA\9E 407 <br />PHONE aos <br />Mel Bokides Petroleum, Inc. <br />209) 472-3491 <br />409. <br />,MAILING ADDRESS <br />PO Box 914 <br />CITY 410- <br />STATE 431. <br />ZIP CODE 411 <br />Lodi <br />CA <br />95241 <br />III. TANK OPERATOR INFORMATION <br />TANK OPERATOR NAME azs-t. PHONE 428-2. <br />Flyers Energy, LLC (530) 885-0401 <br />azs-3 <br />MAILING ADDRESS <br />2360 Lindbergh Street <br />CITY azs-a. <br />STATE azs•s. <br />ZIP CODE 42M. <br />Auburn <br />CA <br />95602 <br />IV. TANK OWNER INFORMATION <br />TAN KOWNERNAME ala. <br />PHONE 435 <br />Mel Bokides Petroleum, Inc. <br />(209) 472-3491 <br />1 <br />416 <br />MAILING ADDRESS <br />PO Box 914 <br />C'fI'1, alp.rST�j\,T—E��41S-ZIP <br />CORE 414 <br />Lodi <br />95241 <br />OWNER TYPE: ❑ 4. LOCAL AGENCY/DISTRICT ❑ 5. COUNTY AGENCY ❑ 6. STATE AGENCY azo. <br />❑ 7. FEDERAL. AGENCY ® S. NON-GOVERNMENT <br />V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br />TY (TK) HQ 44- 0 4 7 4 9 8 Call the State Board of Equalization, Fuel Tax Division, if there are questions. 421. <br />VI. PERMIT HOLDER INFORMATION <br />a23. <br />Issue permit and send legal notifications and mailings to: ❑ 1. FACILITY OWNER ® a. TANK OPERATOR <br />❑ 3. TANK OWNER ❑ 5. FACILITY OPERATOR <br />SUPERVISOR OF DIVISION, SECTION, OR OFFICE (Requit•e(i for Public Agencies Only) 406 <br />VII, APPLICANT SIGNATURE <br />CERTIFICATION: I certify tilat the information rovided herciu is true aecin•ate and in fitil cont iiaiiee witli le al re uirettielits. <br />AP PI r NT SIGNATURF. DATE 424. PHONE azs. <br />10/4/2011 (530) 885-0401 <br />1 <br />AP `T ANNAME (print) 426• <br />APPLICANT TITLE 427 <br />Amanda Appelt <br />Environmental Manager <br />UPCF UST -A Rev. (1212007) -1/2 wimunidocs.org <br />