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09/28/2010 TUE 09:55 FAX 2096`Q3433 SJC EHD 2001 <br /> ********************* <br /> *** FAX TX REPORT *** <br /> ********************* <br /> TRANSMISSION OK <br /> JOB NO. 3684 <br /> DESTINATION ADDRESS 98484282 <br /> PSWD/SUBADDRESS <br /> DESTINATION ID <br /> ST. TIME 09/28 09: 53 <br /> USAGE T 02' 05 <br /> PGS. 5 <br /> RESULT OK <br /> ?I - ( <br /> AA J `6�2�10 <br /> S- <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION 1 1.NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400. <br /> (Check one item only) ❑ 3 RENEWAL PERMIT <br /> ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404' FACILITY ID N41 <br /> (Agency Use Only) <br /> BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3. <br /> BUSINESS SITE ADDRESS 107. CITY 104. <br /> 8 S l �tvr� <br /> FACILITY TYPE 19-I.MOTOR VEHICLE FUELING [:12.FUEL DISTRIBUTION 403 Is the facility located on Indian Reservation or 405. <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER I Trust lands? ❑ 1.Yes 412.No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NA E 407. 1 PHONE 408. <br /> MAILING ADDRESS 409. <br /> CITY 410. STATE 411, 1 LIP CODE 412 <br /> 953 0 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME nn 428-1 PHONE 428.2. <br /> RI-0c'-VII <br /> MAILING ADDRESS 428-7 <br /> CITY 4zsa. STAT 428-s. ZIP CODE 428-6. <br /> �.e <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME <br /> 772 <br /> NE 415. <br /> MAILING ADDRESS 416. <br /> Po Lakl <br /> CIT//Y 4n. STATE 418. ZIPCCODE 419. <br /> C. e <br /> OWNER TYP : ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY Rg�-S.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 1Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421' <br /> VI. PERMIT HOLDER INFORMATION <br />