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U IED PROGRAM CONSOLIDATED FOR]@ <br />co <br />UNDERGROUND STORAGE TANK <br />OPERATING PERMIT APPLICATION - FACILITY INFORMATION J�nfacifity) <br />(One form <br />TYPE OF ACTION ❑ 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 />±.- ' J < <br />FACILITY INFORMATION_ <br />sk. �,_�,� <br />TOTAL NUMBER OF USTsAT FACILITY 404 <br />FACILITY ID # <br />.` <br />I <br />.� <br />(Agency Use Only) <br />A <br />BUSINESS NAME (same as FACILITY NAME or DBA -Doing Business As) 3' <br />Stockton Gas <br />BUSINESS SITE ADDRESS 103. <br />CITY 104. <br />322 South Center Street <br />Stockton <br />FACILITY TYPE ® 1. MOTOR VEHICLE FUELING ❑ 2. FUEL DISTRIBUTION 403. <br />is the facility located on Indian Reservation or 405. <br />❑ 3. FARM ❑ 4. PROCESSOR ❑ 6. OTHER <br />Trust lands? ❑ Yes ® No <br />'IIPROPERTYTOWNERINFORMATION$ <br />PROPERTY OWNER NA407 <br />IL <br />PHONE 4°S. <br />Stockton Gateway Fueling Inc. <br />209-946-4358 <br />MAILING ADDRESS 409 <br />322 South Center Street <br />CITY 410. STATE 411. ZIP CODE 412. <br />Stockton CA 95203 <br />`," ' ';; 'VIII. OPERATO` <br />' , � 2 ;TANK <br />TANK OPERATOR NAME 4za-1. <br />PHONE 4z8 -z <br />GSEP Stations Inc. dba Stockton Gas <br />209-475-0298 <br />MAILING ADDRESS 428-3 <br />322 South Center Street <br />CITY 4284 STATE 428-5 ZIP CODE 428-6 <br />Stockton CA 95203 <br />-4W,, <br />h. fik1 E r, <br />TANK OWNER -INFORMATION = rw € _ ; <br />t� <br />TANK OWNER NAME 414. <br />PHONE 415. <br />Stockton Gateway Fueling Inc. <br />209-946-4358 <br />MAILING ADDRESS 416. <br />322 South Center Street <br />CITY 417. <br />STATE 418. <br />ZIP CODE 419, <br />Stockton 1 <br />CA <br />95203 <br />OWNER TYPE: ❑ 4. LOCAL AGENCYIDISTRICT ❑ 5. COUNTY AGENCY ❑ 6. STATE AGENCY 420 <br />❑ 7. FEDERAL AGENCY ® 8. NON-GOVERNMENT <br />EE'ANT%NUMBER`- <br />LvO'OF�E(/�/U,ALIZATION U5T STURA�GE FCCOU <br />OW <br />TY (TK) HQ 44 Q <br />4 0 6 2 8 Call the State Board of Equalization, Fuel Tax Division If there are questions 421 <br />nwmx <br />� �i 3r YS,r i1 k��, .R��,'7s. <br />- <br />.�w'-F �� ��C�U:.`�v '�' Y .:�$. -a h'. ad,� sit .,.?� ,x, x, t � •,.�L .o -.N 7 ..C,. �. �w E'� f 4...x,-, <br />y ,., ,Y. •,�.� <br />... <br />423 <br />Issue permit and send legal notifications and mailings to: ®1. FACILITY OWNER ❑ 4. TANK OPERATOR <br />❑ 3. TANK OWNER ❑ 5. FACILITY OPERATOR <br />SUPERVISOR OF DIVISION, SECTION, OR OFFICE (Required For Public Agencies Only) 406. <br />`Fwsti-`. r �' a �f W "F� S•n,• y- ,. '4w. t [ 4 <br />APPLYCANT,SIGNATURE_ <br />.bt ra „� <br />CERTIFICATION: I certify that the information provided herein is true, accurate, and in full compliance with legal requirements. <br />PLICAN SIGNATU <br />-P" S• pp <br />DATE 424. <br />�a )1 <br />PHONE 425. <br />209-475-0298 <br />APPLICANT NAME (print) 426. <br />APPLICANT TITLE 421 <br />Amar'it Rai <br />Secretary <br />UPCF UST -A Rev. (12/207) <br />