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UNIFIED PROGRAM CONSOLIDATED FORM 11IIB1 n <br /> UNDERGROUND STORAGE TANK <br /> E:OPERATING PERMIT APPLICATION- FACILITY INFORMATION <br /> (One form per facility) 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 /> T I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404' FACILITY ID# <br /> 1 (Agency Use Only) <br /> BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3' <br /> Bank of Stockton <br /> BUSINESS SITE ADDRESS 103. CITY 104. <br /> 1941 E. Lockheed Ct 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 ® 2.No <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 4N. <br /> County Of San Joaquin 209 468-4700 <br /> MAILING ADDRESS 409. <br /> 5000 S Airport Way <br /> CITY 410. 1 STATE 411. ZIP CODE 412. <br /> Stockton CA 95206 <br /> M. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. PHONE 428-2. <br /> Bank of Stockton (209)483-0257 <br /> MAILING ADDRESS 428-3. <br /> P. O. Box 1110 <br /> CITY 428-4. 1 STATE 428-5. ZIP CODE 428-6. <br /> Stockton CA 95201 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> Bank of Stockton (209)483-0257 <br /> MAILING ADDRESS 416. <br /> P.O. Box 1110 <br /> CITY 417. 1 STATE 418. ZIP CODE 419. <br /> Stockton CA 95201 <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- 10 1 '2-1 (I-lq 1-7,10Call the State Board of Equalization,Fuel Tax Division,ifthere are questions. 421. <br /> VI. PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: ❑ 1.FACILITY OWNER El4.TANK OPERATOR 423. <br /> ® 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required for Public Agencies Only) <br /> VII.APPLICANT SIGNATURE <br /> CER CATION: I certify thatt e information ded herein is true,accurate,and in full com liance with 1 al r uirements. <br /> APP C IGNAT JRE DATE 424. 1 PHONE <br /> 11/8/2011 208 483-0257 t <br /> j <br /> PLjQ NAME(print) 426. APPLICANT TITLE _...�27 <br /> Norman L White VP Chief Pilot <br /> UPCF UST-A Rev.(12/2007)-1/2 www.unidocs.ore <br /> LAB <br />