Laserfiche WebLink
Alk AdL <br /> Put IFIED PROGRAM CONSOLIDATED FO a <br /> UNDERGROUND STORAGE TANK <br /> E:OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION ❑ 1.NEW PERMIT ® 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 " FACILITY!D# t. <br /> 3 (Agency Use Only) - <br /> BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3 <br /> Gas Depot <br /> BUSINESS SITE ADDRESS 103" CITY 104" <br /> 1330 Ave.E. Yosemite Manteca <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 /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407-T PHONE 408. <br /> Kevin Hur (209) 825-7722 <br /> MAILING ADDRESS 409" <br /> 1330 E. Yosemite Ave. <br /> CITY 410" STATE 411 ZIP CODE 412. <br /> Manteca Ca. 95336 <br /> M. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 4215 1" PHONE 428-2• <br /> Same ( ) <br /> MAILING ADDRESS 428 a <br /> CITY 42&4. STATE 428 s. ZIP CODE 428-6. <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME ata- PHONE 415. <br /> Same ( ) <br /> MAILING ADDRESS 416 <br /> CITY 457 STATE 418. 1 ZIP CODE 419. <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 0 14 13 13 17 1 5 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 /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Requiredfor Public Agencies Only) 466. <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that a information provided here' is true,accurate,4nd in fqil compliance with legal requirements. <br /> APPLICANT SIGNATURE DATE 424. PHONE 425. <br /> - A K_ (209) 825-7722 <br /> APPLICANT NAME 426 APPLIC TI L 427 <br /> Kevin Hur Owner <br /> UPCF UST-A Rev.(12/2007)-1/2 w'ww.unidocs.org <br /> i <br />