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09/27/2010 MON 14: 43 FAX 2094683433 SJC EHD 0001 <br /> ********************* <br /> *** FAX TX REPORT *** <br /> ********************* <br /> TRANSMISSION OK <br /> JOB NO. 3680 <br /> DESTINATION ADDRESS 98484282 <br /> PSWD/SUBADDRESS <br /> DESTINATION ID <br /> ST. TIME 09/27 14: 41 <br /> USAGE T 02' 42 <br /> PGS. 6 <br /> RESULT OK <br /> UNIFIED PROGRAM CONSOLJDATED FORM <br /> UNDERGROUND STORAGE TANK II <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facility) <br /> �.PERMANENT FACILITY CLOSURI; <br /> TYPE OF ACTION I.NEW 1MfT,E ❑ 5.CHANGE OF INFORMATION 6.TEMPORARY FACII.rry CLOSURE ❑ 9.TRANSFER PERMIT <br /> (CArct one iron only) 13� 3.RENEWAL <br /> 1YAL PER ❑ <br /> I. FACILITY WFORMATION 1 <br /> TOTAL NUMBER OF USTs AT F ILITY eo+ FACILITY oACT Only) — �� <br /> i31 QdESS NAMIm.(Came m Facility Mmne or DBA—Doing Burnes AV <br /> �cwL!L ` C L ma mot. <br /> BUSINESS SITE ADDRESS <br /> C-- 405. <br /> 40' 1s the fsclity IOU"on Indian Resxrvation or <br /> FACILITY TYPE ❑ I.MOTOR VEHICLE FUELING Cl 2,FUEL DISTRIBUTION Twst Wtds9 Cl 1.Yes 2.No <br /> 3.FARM 4.PROCESSOR1A 6.OTHER <br /> IL PROPERTY OWNER INFORMATION <br /> wr. PHONE <br /> PROPERTY OWNER NAME <br /> MA1L1`�fl"ADDRESS <br /> 1 1✓, PJ,� �— Oto. TE 41m. ZIP CODE 412, <br /> g <br /> CITY M <br /> HL TANK OPERATOR INFORMATION �z <br /> ux 1. PHONE <br /> TAN O�p RNAME f,u� <br /> v� 1zs-3. <br /> MAILING ADDRESS <br /> L �J• (r<i i; 'L F"f'Jl__ ZIP CODE 4z w <br /> 4zs-•t. rcTE s. 5�3 3� <br /> IV. TANK OWNER INFORMATION <br /> ars. PHONE 415 <br /> TANK OWNER NAME <br /> 41(. <br /> MAILING ADDRESS <br /> 4n. <br /> 4ms. ZIPCODE 419. <br /> CITY STATE <br /> OWNER TYP1i ❑4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ <br /> 6-STATE AGENCY 47J' <br /> ❑ 7.FEDERAL.AGENCY, ❑ 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER 421 <br /> Call the State Board of EA1lalUation,Fuel Tax Division,if there are questions. <br /> Ty(TIC)HQ 44 <br /> VL PERMIT HOLDER INFORMATION 423. <br /> 1.FACILITY OWNER ❑ 4.TANK OPERATOR <br /> permit Iss. and send legal notifications and malltngs t°: ❑ 3.TANK OWNER 5.FACILITY OPERATOR <br /> aa. <br /> SUPERVISOR OF DIVISION,SECTION,OROFFICE{Requirrdfor Public.4gencies Only) <br />