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I <br /> UNIFIED PROGRAM CONSOLIDATED FORINI <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION — FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION' ❑ I NEW PERMIT ® 5.CHANGE OF INFORMATION (37.PERMANENT FACILITY CLOSURE; <br /> 400. <br /> (Check one item only) ❑ 3 RENEWAL PFRMIT ❑ 6.TF.MPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL.NUMBER OF USTs AT FACILITY <br /> 2 (.'Egelacy(lee Onl3) f� <br /> BUSINESS NAM F.(Sane as F'acilhy Name or 08A- Domg llr!siness.ls) <br /> C Stop 45449 <br /> BUSINESS SITE ADDRESS 103 CITY 104- <br /> 322 South Center Street Stockton <br /> FACILffY'fYPE [3I.i40'fOR VEI IICLfi Fl1E LING 1 C12 FILE°L DIDISTRIBUTIONDISTRIBUTION403. Is the facility located on Indian Reservation or 405. <br /> C]; 3,FARM -M 4.PROCESSOR i C36 OTHER <br /> frust lands? ❑ 1.Yes ] 2 No <br /> _ II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 40A, <br /> Pacific Convenience and Fuels, LLC 925 884-0800 <br /> MAILING ADDRESS 409- <br /> 7108 Koll Center Parkway, Suite 100 <br /> CITY 410 STATE' CA <br /> ZIP CODE; 412. <br /> Pleasanton CA 94566 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAMEi7925 <br /> HONE: 428-2. <br /> Pacific Convenience and Fues, LLC } 884-0800 <br /> MAILING ADDRESS 428.3 <br /> 7108 Koll Center Parkway, Suite 100 <br /> CITYSTATE 428.5 ZIP CODE 428-6. <br /> Pleasanton4Y84' CA 94566 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME: 41a. PHONE 41s. <br /> Pacific Convenience and Fuels, LLC (925 ) 884-0800 <br /> MAILING ADDRESS ' 416. <br /> 7108 Koll Center Parkway, Suite 100 <br /> CITY 417 STATE: 4t8 ZIPCODE 419 <br /> Pleasanton CA 94566 <br /> OWNERTYPF ❑ .i LOCAL AGFNCYDISTRIC.F ( 5.t'011NTY A(iFNCY ❑ 6 SfATF AGFNC'Y Oto <br /> ❑ 7 FEUFRAL AGENCY (R 4,NON-GOVERNMENT <br /> V. BOARD OF EQUALIZ4TION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- d 14 16 13 15 4 Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421' <br /> I VI. PERMIT HOLDER INFORMATION <br /> Issue permit and send lepi notifications and mailings to 423 <br /> Pe !7A is I.FACILITY OWNER ❑ 4.TANK OPERATOR <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OI'DIVISION,SECTION,OR OFFICE(Requited for Public Agencies Only) 406, <br /> 1 VII]APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that the information prilivided herein is true,accurate,and in full compliance with legal re uirements. <br /> APPLICANTSIGNAIUtRE .c' DATE 424 <br /> PHONE. 425. <br /> APPLI1 <br /> CANT NAME.(print) —' 4=6 APPLICANT 11111 427 <br /> UPCF UST-A Rev.(17/1007)-1i2 www.unidoes.org <br />