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LIMMIED PROGRAM CONSOLIDATED FORM-�L_,_ <br />UNDERGROUND STORAGE TANK L <br />OPERATING PERMIT APPLICATION - FACILITY INFORMATION' <br />u', (Onei per facility) <br />TYPE OF ACTION ❑ 1. NEW PERMIT 0 5. CHANGE OF INFORMATION ❑ 7. PERMANENT FACILITY CLOSURE 4C <br />(Check one item only) ❑ 3. RENEWAL PERMIT 0 6. TEMPORARY FACILITY CLOSURE 0 9. TRA ERPERM <br />IT <br />TOTAL NUMBER OF USTs AT FACILITY 41. <br />FACILITY ID # <br />(A&ency Use Only) <br />BUSINESS NAME (S. as FACILITY NAME or DBA - Doing Business As) 3. <br />California Highway Patrol #265 <br />BUSINESS SITE ADDRESS 103. CITY 104. <br />3330 North Ad Art Road Stockton <br />0 <br />FACILITY TYPE ®1. MOTOR VEHICLE FUELING ❑ 2. FUEL DISTRIBUTION 403. Is the facility located on Indian Reservation L 40s. <br />[71 3. FARM 0 4. PROCESSOR [1 6. OTHER Trust lands? [] Yes [:1 No <br />California Highway Patrol <br />(916) 843-3806 <br />MAILING ADDRESS 409. <br />3330 North Ad Art Road <br />CITY 410. <br />STATE 411. <br />ZIP CODE 412. <br />Stockton <br />CA <br />95215 <br />M., TANK OPERATOR INFORMATION <br />TANK OPERATOR NAME 428-1. PHONE 428-2 <br />California Highway Patrol (916) 843-3806 <br />MAILING ADDRESS 428-3 <br />3330 North Ad Aft Road <br />CITY 4284 <br />STATE 428-5 <br />ZIP CODE 428-6 <br />Stockton <br />CA <br />95215 <br />IVTANK OWNER INFORMATION <br />TANK OWNER NAME 414. <br />PHONE 415. <br />California Highway Patrol <br />(916) 843-3806 <br />MAILING ADDRESS 416. <br />PO Box 942898 <br />CITY 417. <br />STATE 418. <br />ZIP CODE 419. <br />Sacramento <br />� CA <br />94298 <br />OWNER TYPE: [1 4. LOCAL AGENCY/DISTRICT ❑ 5. COUNTY AGENCY 6. STATE AGENCY 420. <br />[1 7. FEDERAL AGENCY ❑ 8. NON-GOVERNMENT <br />I TY (TK) HO 44- 1 0 1 3 1 2 1 0 1 6 1 2 1 Call the State Board of Equalization, Fuel Tax Division, if there are questions. 4Z 1. 1 <br />Issue permit and send legal notifications and mailings to: [1 1. FACILITY OWNER ❑ 4. TANK OPERATOR <br />El 3. TANK OWNER 5. FACILITY OPERATOR <br />SUPERVISOR OF DIVISION, SECTION, OR OFFICE (Required For Public Agencies Only) Beth DEPaola 406. <br />VII. APPLICANT SIGNATURE <br />CERTIFICATION: I certify that the informok!yarovided herein is true accurate, and in full compliance with legal requirements. <br />APPLICANT SIGNATURE DATE 424. 1 PHONE 421, <br />7/12/2017 (805) 929-8944 ext 1002 <br />APPLICANT NAME (print) 426. APPLICANT TITLE 427 <br />Glenn Paredes Project Coordinator <br />UPCF UST -A Rev. (12/2007) <br />