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0 0 <br /> UNIFIED PROGRAM CONSOLIDATED FORM f <br /> UNDERGROUND STORAGE TANK o <br /> OPERATING PERMIT APPLICATION- FACILITY INFOR1VrWION' <br /> (One form per facility) <br /> TYPE OF ACTION ❑ I.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 SAN <br /> I. FACILITY INFORMATION =i,wra ```•`' <br /> TOTAL NUMBER OF USTs AT FACILITY 4°4. FACILITY ID it I I _ I _ t <br /> 3 (Agency Use Only) <br /> BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3. <br /> B &W PETROLEUM # 98 dba H & M MARKET <br /> BUSINESS SITE ADDRESS f03 CITY 104 <br /> 2501 JACKSON ST. ESCALON, CA. 95320 <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, PHONE 409. <br /> PHILIP MATTHEWS 408) 336-2549 <br /> MAILING ADDRESS 409• <br /> 532 COON HEIGHTS RD, STATE <br /> CITY 410• 411. ZIP CODE 412, <br /> BEN LOMOND CA 95005 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. PHONE 428.2. <br /> B &W PETROLEUM (209) 577-6000 <br /> MAILING ADDRESS 4283. <br /> 601 Mc HENRY AVE. <br /> CITY 428-4.t STATE 428-5. ZIP CODE 429.6. <br /> MODESTO CA 95350 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415, <br /> B &W PETROLEUM (209) 577-6000 <br /> MAILING ADDRESS 416. <br /> 601 Mc HENRY AVE. <br /> CITY 4FJ STATE 418. ZIP CODE 419• <br /> MODESTO CA 95350 <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- 1015101315161 Cali 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 Z 4.TANK OPERATOR 423. <br /> ❑ 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 tghk thi i6lArmation provided herein is true,accurate,and in full compliance with legal requirements. <br /> APPLICANT SIGNATURE 'JjjjDATE 424. PHONE 425. <br /> ,�Vzd& 9/30/2011 209 577-6000 <br /> APPLICANT NAME(print) 426• 1 APPLICANT TITLE 427 <br /> B & W PETROLEUM IT ROHDA HEN6--) CUSTOMER SERVICE COORDINATOR <br /> UPCF UST-A Rev.(12/2007)-1/2 www.unidocs.org <br />