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01/13/2009 TUE 16: 11 FAX 20943433 SJC EHD 0009/013 <br /> UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUNDSTORAGETANKOPERATING PERMIT APPLICATION- FACILITY INFORMATION(One form per facility) Ii9 <br /> TYPE OF ACTION ❑ I.NEW PERMIT 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 100' <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 904' FACILITY ID it 01 Q A r <br /> (Agency Use Only) �- <br /> BUSINESS NAM (Satre as FacililyMnt or DBA--Doing 13usfness As) 3• <br /> '00)0.64 4iP &r -o-35- <br /> BUSINESS SITE ADDRESS 103. CITY 104• <br /> FACILITY TYPE ® I.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 463. Is the foci located on Indian Reservation or 4os. <br /> 'y <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑ I.Yes ;&2.No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 1 402. 1 PHONE 408. <br /> MAILING ADDRESS 409• <br /> CITY 410 1 STATE 411. 1ZIP CODE 412• <br /> CA 9 5- <br /> 111. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME _ 425.1. PHONE 428'2• <br /> /C 373-1159 <br /> MAILING ADDRESS 423-3• <br /> CITY 423.4• STATE 128-5• ZIP CODE 428.6• <br /> �- X4,17` <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NZle-e_ <br /> 414. PHONE 415. <br /> 130A) M.44 �uC (4/09 ) 0' .- g ;. <br /> MAILING ADDRESS 416• <br /> Z/C ! 2 l/a;A <br /> CITY / 417. STATE 415. ZIP CODE 419. <br /> 1 0 <br /> OWNER TYPE. ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 1420• <br /> ❑ ?.FEDERAL AGENCY ❑ 8.NON-GOVERNMENT CO & 1J <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUN NUMBER <br /> TY(TK)HQ 44- Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421. <br /> VI. PERMIT HOLDER INFORMATIONCAII q/&- 3� Colo <br /> Issue permit and send legal notifications and mailings to: ❑ I.FACILITY OWNER ❑ 4.TANK OPERATOR 123' <br /> Pa 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required for Public Agencies 0111y) 406. <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that the information provided herein is true accurate and in full compliance with legal re uiremeuts. <br /> APPLICANT SIGNATURE DATE 424. PHONE 425. <br /> APPLICANT NAME(print) 4'-6, APPLICANT TITLE 427 <br /> �56 ;;E--( A2e,4L7 ' e c__ho62 <br /> UPCF UST-A Rev.(12/2007)-1/2 www.unidocs.org <br />