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0912512009 13:13 2094749151 HAMMER I5 ARCO PAGE 03116 <br /> ' UNUUD PROGRAM CONSOLIDATED FORM r�UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION Q VVI <br /> (Ono form per facility) <br /> TYPE OF ACTION ❑ 1.NEW PERNUT 5.CHANGE OF INFORMATION ❑ 7,PERMANENT FACILITY CLOSURE 400. <br /> (C/ ck Ole item Only) ® 3.RENEWAL PERMIT ❑ 6.TEMPORARY"FACILrrY CLOSURE [] 9.TRANSFER PERMIT <br /> 7!:!! <br /> 3 �Agery use orlITTI <br /> BUSINESS N (Same as,Facility Ncrae or DBA-,Doing.business As) 3. <br /> Hammer/1-5 Arco <br /> BUSINESS SITE ADDRESS 103. CITY 104. <br /> 3250 W. Hammer Lane Stockton <br /> FACILITY TYPE 0 1.MOTOR VF.FIICLE FUELING ❑ 2.FUEL DISTRIBUTION 463' Is the facility located on Indian Reservation or 40S <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHM Trust lands? ❑ 1.Yes ® 2.No <br /> PROPERTY OWNER NAME 407. PHONE 403. <br /> Robert J. Parkinson 209 951-5671 <br /> 409. <br /> MAILING ADDRESS <br /> 6669 Embarcadero Dr. #1 <br /> CrTy STATE az►. ZIP CODE °1� <br /> Stockton GA 95219 <br /> TANK OPERATOR NAIvIlr 4za r. pIION= 4sa 2. <br /> Weslev Parkinson (209)474-9125 <br /> 429-3.MAILINCr ADDRESS <br /> 3250 W. Hammer Lane ...... ..___ <br /> CITY 42$4. STATE 42R.s. ZI(CODE 42". <br /> Stockton CA 195209, <br /> MONOMER= <br /> TANK OWNER NAME 4t4. PHONE 415• <br /> Wesle Parkirison (209) 474-9125 <br /> MAILING ADDRESS its. <br /> 3250 W. Hammer Lane <br /> 4n. STATE ata. ZIP CODE 419. <br /> CITY <br /> Stockton CA 95209 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCYIDISTRICT ❑ 3.COUNTY AGENCY ❑ 6.STATE.AGENCY d2O• <br /> ❑ 7,FEDERAL AGENCY ® 8.NON-GOVERNMENT <br /> Ty(TK)uQ 44- 10 1 2 14 19 j 81 6 Call the State Board of Equali=dot,Fuel Tax INvision,if there are questions. azt. <br /> III INIONNOMM <br /> Issue pemut and scud Icgal notifications sled rAtallings to: ❑ 1.FACILITY OWNER ❑ d.TANK OPERATOR <br /> ® 3.TANK OWNER ❑ 5.FACILITY OPERATOR `\ <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Regulredfor,Public Agencies Only) <br /> I <br /> CERTM TION: I cergt that tate Information provided herein is true ucurate,aed in full com Bance with I IuiiremFJMIIS-T� <br /> AP�pI SI 424. <br /> 9/21/2009 (209) 474-9125 <br /> LIC AME(print) 4z6. APPLlC:AN'1't1TLE <br /> 1�7 <br /> Wesl Parkinson Owner <br /> UPCF UST A)Rev.(121207).]/Z www_ <br /> aRidomor$ <br /> t � � <br />