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REMOVED <br /> UNIFIED PROGRAM CONSOLIDATED FORM FEB 1 8 �' Llby <br /> UNDERGROUND STORAGE TANK I <br /> OPERATING PERMIT APPLICATION- FACILITY INFQRMAMT HEALTH <br /> (One form per facility) PERMIT/SERVICES <br /> TYPE OF ACTION ❑ 1.NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLO RE400 <br /> (Check one item only) ® 3 RENEWAL PERMIT [:] 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT CVVI <br /> I. FACILITY INFORMATION �, D Q� <br /> TOTAL NUMBER OF USTs AT FACILITY 404. FACILITY ID# <br /> 1 (Agency Use Only) CJ <br /> BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3. <br /> California Highway Patrol <br /> BUSINESS SITE ADDRESS 103. CITY 104. <br /> 3330 North Ad Art Road Stockton <br /> FACILITY TYPE ® 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403. Is the facility located on Indial 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 408. <br /> California Highway Patrol 916 375-2940 <br /> MAILING ADDRESS 409. <br /> P. O. Box 942898 <br /> CITY 410. 1 STATE 411. ZIP CODE 412. <br /> Sacramento CA 94298-0001 <br /> M. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. PHONE 428-2. <br /> California Highway Patrol (209) 943-8666 <br /> MAILING ADDRESS 428-3. <br /> 3330 North Ad Art Road <br /> CITY 428-4. 1 STATE 428-5. ZIP CODE 428-6. <br /> Stockton CA 95215 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> California Highway Patrol (916) 375-2940 <br /> MAILING ADDRESS 416. <br /> P. O. Box 942898 <br /> CITY 417. 1 STATE 418. ZIP CODE 419. <br /> Sacramento CA 94298-0001 <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- 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 OPERATORF, <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required for Puhlic Agencies Only) 406. <br /> VII.APPLICANT SIGNATURE : <br /> CERTIFICATION: I certify that the information provided herein is true,accurate,and in full com liance with legal requirements. <br /> APPLICANT SIGjqAT RE DATE 424. PHONE 425. <br /> PLICANT NAME(print) 426. APPLICANT TITLE 427 <br /> ZJ <br /> UPCF UST-A Rev. 12/2007 -1/2 www.unidoes.org ¢ <br />