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C§gerd:j?y1 q.NUerjj,gn #427, Not Yet Submitted <br /> 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 El 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 41"1 <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# <br /> 3 (Agency Use Only) <br /> BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3. <br /> FLYERS#427 <br /> BUSINESS SITE ADDRESS 103, CITY 104. <br /> 3300 Waterloo Rd. Stockton <br /> FACILITY TYPE 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403 Is the facility located on Indian Reservation or 405 <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑ l.Yes 2.No <br /> IL PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 408. <br /> Nella Properties LLC 530-885-0401 <br /> MAILING ADDRESS 409 <br /> 2360 Lindbergh St. <br /> CITY 410 STATE 411. ZIP CODE 412 <br /> Auburn CA 95602 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1 PHONE 428-2 <br /> Flyers Energy LLC 530-885-0401 <br /> MAILING ADDRESS 428-3 <br /> 2360 Lindbergh St: <br /> CITY 4284. 1 STATE 428-5. ZIP CODE 428-6 <br /> Auburn CA 195602 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> Flyers Energy LLC 530-885-0401 <br /> MAILING ADDRESS 416 <br /> 2360 Lindbergh St. <br /> CITY 417. STATE 418. ZIP CODE 419. <br /> Fair Oaks CA 95602 <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 USTSTORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 10 4 2 9 2 1 1 Call the State Board of Equalization,Fuel Tax Division,if there are questions 421 <br /> VI. PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: ❑ 1.FACILITY OWNER ❑ 4.TANK OPERATOR 423 <br /> Q 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 liance with legal requirements. <br /> ANT SIGNATURE DATE 424 PHONE 425. <br /> 2011/09/30 530-885-0401 <br /> A PLI ANT NAME(print) 426 APPLICANT TITLE 427 <br /> Amanda Appelt Environmental Manager <br /> UPCF UST-A Rev.(12/2007)-1/2 www.unidoes.org <br /> Glick Plea to unlock 1'DFKit.NETlull �[ <br /> 1 > <br />