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o0 3 a5ao � fo <br /> UNIFIED PROGRAM CONSOLIDATED FORM ( n C) <br /> UNDERGROUND STORAGE TANK l <br /> OPERATING PERMIT APPLICATION - FACILITY INFORMATION � ilI� y � 11 <br /> (One form per facility) <br /> TYPE OF ACTION ❑ L NEW PERMIT ❑ 5 . CHANGE OF INFORMATION ® 7. PERMANENT FACILITY CLOSURE 4D0 <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 # <br /> 1 1 (Agency Use Only) <br /> BUSINESS NAME (Same as FACILITY NAME or DBA - Doing Business As) 3. <br /> DBL Rentals <br /> BUSINESS SITE ADDRESS 103. CITY 104• <br /> 619 and 625 North Sacremento Street Lodi, CA <br /> FACILITY TYPE ❑ 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 ® No <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407• PHONE 408. <br /> John Bubica 209 625-5261 <br /> MAILING ADDRESS 409. <br /> 701 South Ham Lane Suite C <br /> CITY 410. STATE 411 • ZIP CODE 412. <br /> Lodi CA 95242 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1 . PHONE 428-2 <br /> John Bubica (209) 625 -5261 <br /> MAILING ADDRESS 428-3 <br /> 701 South Ham Lane Suite C <br /> CITY 428-4 TSTATE 428-5 ZIP CODE 428-6 <br /> Lodi ICA 95242 <br /> IV. TANK OWNER INFORMATION <br /> i <br /> TANK OWNER NAME 414, PHONE 415. <br /> John Bubica (209) 625 -5261 <br /> MAILING ADDRESS 416. <br /> 701 South Ham Lane Suite C <br /> CITY 417. STATE 418. ZIP CODE 419. <br /> Lodi CA 95242 <br /> OWNER TYPE: ❑ 4. LOCAL AGENCY/DISTRICT ❑ 5. COUNTY AGENCY ❑ 6. STATE AGENCY 420. <br /> ❑ 7. FEDERAL AGENCY ® 8. NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY (TK) HQ 44- 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: ® 1 . FACILITY OWNER ❑ 4. TANK OPERATOR 423 <br /> ❑ 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 compliance with legal requirements . <br /> APP AN IG RE DATE 424. PHONE 425 . <br /> AIPPL.Iij .. T/jAME (print) 426. AP L�TITLE 427 <br /> UPCF UST-A Rev. ( 12/2007) <br />