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UNIFIED PROGRAM CONSOLIDATED FORM . � � w <br /> UNDERGROUND STORAGE TANK -WG v <br /> OPERATING PERMIT APPLICATION - FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION ❑ 1.NEW PERMIT Z 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400 <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 /> Nella Oil #427 dba Olympian PL E) 1, <br /> BUSINESS SITE ADDRESS 103. CITY 104. <br /> 3300 Waterloo Road 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? ❑ 1.Yes Z 2.No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408. <br /> Flyers LLC (530) 885-0401 <br /> MAILING ADDRESS 409 <br /> 2360 Lindbergh Street <br /> CITY 410. STATE 411 ZIP CODE 412, <br /> Auburn CA 195061 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. PHONE 428-2 <br /> Nella Oil Company LLC (530) 885-0401 <br /> MAILING ADDRESS 428 3 <br /> 2360 Lindbergh Street <br /> CITY 428-4 STATE 428-5 ZIP CODE 428-6. <br /> Auburn CA 95602 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> Nella Oil Company LLC (530) 885-0401 <br /> MAILING ADDRESS 416. <br /> 2360 Lindbergh Street <br /> CITY 417. STATE 418. ZIP CODE 412 <br /> A;mburn CA 95602 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY Z 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 10111918191 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 /> Z 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 legal requirements. <br /> AP ANT SIGNATURE DATE 424. PHONE 425. <br /> 9/10/2008 (530) 885-0401 <br /> PLICANT N E(print) 426. APPLICANT TITLE 427 <br /> Amanda Appelt Environmental Manager <br /> UPCF UST-A Rev.(12/2007)-1/2 www.unidocs.org <br />