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IED PROGRAM CONSOLIDATED FORW <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION X 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 404' FACILITY ID# 1 <br /> 3 (Agency Use Only) <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3. <br /> New West#1003 <br /> BUSINESS SITE ADDRESS 103. CITY 104, <br /> 6437 W. Banner Road Lodi <br /> FACILITY TYPE x 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? ❑Yes x No <br /> IL PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 408. <br /> New West Stations 916-443-0890 <br /> MAILING ADDRESS 409. <br /> 1831 16th Street <br /> CITY 410. STATE 411. ZIP CODE 412. <br /> Sacramento CA 95814 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-I. PHONE 428-2 <br /> New West Stations 916-443-0890 <br /> MAILING ADDRESS 428-3 <br /> 1831 16th Street <br /> CITY 428-4 STATE 428-5 ZIP CODE 428-6 <br /> Sacramento CA 95814 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> New West Stations 916-443-0890 <br /> MAILING ADDRESS 416. <br /> 1831 16th Street <br /> CITY 417. STATE 418. ZIP CODE 419- <br /> Sacramento CA 95814 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY azo. <br /> ❑ 7.FEDERAL AGENCY X 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 1 1 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: El1.FACILITY OWNER [14.TANK OPERATOR 423 <br /> X 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 that the information provided herein is true,accurate,and in full com Bancewith le al requirements. <br /> APPLICANT TURE DATE 424. PHONE 421. <br /> lD - C (916) 373-1166 <br /> APPLICANT N (print) 426. APPLICANT TITLE 42� <br /> Dulcinea Webb Compliance Manager <br /> UPCF UST-A Rev.(12/2007) <br />