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t-! ' <br />1 <br />UNIFIED PROGRAM CONSOLIDATED FORM <br />UNDERGROUND STORAGE TANKN1ENT HEAL f <br />OPERATING PERMIT APPLICATION -FACILITY INFORM /SE4V!CES <br />„ <br />(One form per facility) <br />TYPE OF ACTION ❑ L 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 />I. FACILITY INFORMATION <br />TOTAL NUMBER OF USTs AT FACILITY 4N. <br />1 FACILITY ID #_ <br />JFJ <br />11l <br />C7 <br />C <br />_ <br />L� <br />Z <br />�` j11 <br />1 <br />1. <br />42 <br />(Agency Use Only) <br />BUSINESS NAME (Same as Facility Name or DBA -Doing Business As) 3. <br />Cl or( <br />BUSINESS SITE ADDRESS 103. <br />CITY 1a. <br />R, �M <br />FACILITY TYPE ❑ I. MOTOR VEHICLE FUELING 2. FUEL DISTRIBUTION 413. <br />Is the facility located on Indian Reservation or 405. <br />❑ 3. FARM ❑ 4. PROCESSOR ❑ 6. OTHER <br />Trust lands? ❑ I. Yes X 2. No <br />II. PROPERTY OWNER INFORMATION <br />PROPERTY OWNER NAME 403 <br />PHONE ,.Z..Iy.0�$ °oe. <br />MAILMG ADDRESSI)f 4W <br />Z S A/ vk <br />CITY 410. <br />STATE 411. <br />ZIP CODE 412 <br />C.4 <br />9s3✓a� <br />��. <br />III. TANK OPERATOR INFORMATION <br />TANK OPERATOR NAME 428-1 <br />PHONE 428-2. <br />ivr4 <br />c ) <br />MAILING ADDRESS 4293, <br />CITY 4284. 1 <br />STATE 4295. <br />ZIP CODE 429x. <br />IV. TANK OWNER INFORMATION <br />TANK OWNER NAME II (r' 414_ <br />PHONE 2 p 415. <br />C1e <br />(2oT)S9i-/ <br />7aT <br />MAILING ADDRESS 1 416' <br />25 ( AW. /I <br />CITY 417, <br />(Z <br />STATE 419, <br />ZIP CODE 419. <br />CA <br />f53(.� <br />OWNER TYPE: If& 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- 1 1 1 /qj A I I ICall 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 (Requiredfor 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 />APPLICANT SIGNATOR > <br />DATE 424. <br />PHONE 4u. <br />5-- /5r - 69 1 <br />2,o9 S99 - Z/ 5 <br />APPLICANT NAM <br />(print)' 426 <br />APPLICANT TITLE// 427 <br />ON �N! <br />Pvis&je &Jot.kS b7recfO.t. <br />UPCF UST -A Rev. (1212007) - 112 www.unidocs.org <br />