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PR n 54-) 41 tp <br />UNIFIED PROGRAM CONSOLIDATED FORM <br />UNDERGROUND STORAGE TANK <br />OPERATING PERMIT APPLICATION — FACILITY INFORMA�brocqe <br />er facility) <br />TYPE OF ACTION I. NEW PERMIT [:35. CHANGE OF INFORMATION [-]7. PERMANENT FACILITY CLOSURE 400. <br />(Check one item only) ❑ 3. RENEWAL PERMIT ❑ 6. TEMPORARY FACILITY CLOSURE ❑ 9. TRAIRIEWMENTAL HEALTH <br />I. FACILITY INFORMATION �,�, DEPARTMENT 2 <br />TOTAL NUMBER OF USTs AT FACI_ LITS 404 <br />FACILITY ID 4 <br />(Agency Use Onty) <br />BUSINESS NAME (Seine a9 FACILITY NAME or DBA -Doing Business As) C 3. <br />/' <br />C <br />7 L ` J <br />BUSINESS SITE ADDRESS ioi. <br />^� L4tjc <br />CITY 104. <br />Lo�� s�Xyz <br />FACILITY TYPE . MOTOR VEHICLE FUELING ❑ 2. FUEL DISTRIBUTION 403. <br />Is the facility Iocated on Indian Reservation or 405' <br />❑ 3. FARM ❑ 4. PROCESSOR ❑ 6. OTHER <br />Trust lands? []Yes ❑ No <br />II. PROPERTY OWNER INFORMATION <br />PROPERTY O'�I$R NAME 11 ^ 407- <br />PHONE 40e. <br />�� S <br />h` <br />MAILIN ADDRESS 009, <br />qba LH <br />CITY 410 <br />Yf�1 v <br />STATE A 411. <br />— " <br />ZIPCODE 412. <br />, <br />III. TANK OPERATOR INFORMATION <br />TANK OPERATOR.NAME 429-1_ <br />PHONE 428-2 <br />MAILING ADDRESS 428-3 <br />/0 C ► L- , <br />CITY 4284 <br />STAT 428-5 <br />ZIP CODE 428-6 <br />s6 <br />RY Is <br />IV. TANK OWNER INFORMATION <br />TANK OWNEE 414. <br />PHONE 415_ <br />fm &r4% L� <br />(lam ) <br />MAILING ADDRESS als_ <br />LES <br />CITY ^ 4n.• <br />STAT 418. <br />ZIPCODEn5/6 I(f 419, <br />OWNER TYPE: F]4. LOCAL AGENCY/DISTRICT ❑ 5. COUNTY AGENCY ❑`"'66. STATE AGENCY 420_ <br />❑ 7. FEDERAL AGENCY .NON-GOVERNMENT <br />V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br />TY (TK) HQ 44- 1 1 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: I .FACILITY OWNER ❑ 4. TANK OPERATOR 423 <br />❑ 3. TANK OWNER ❑ 5. FACILITY OPERATOR <br />406 <br />SUPERVISOR OF DIVISION, SECTION, OR OFFICE (Required For Public Agencies Only) <br />\1 <br />VIL APPLICANT SIGNATURE <br />CERTIFICATION: 1 cert that the information provided herein is true, accurate, and in full compliance with legal requirements. <br />APPLICANT SIGNATURE <br />DATE 424 <br />PHONE 425 <br />// b4il. <br />91 0 <br />APPLICANT ME (print)426. <br />APPLICANT TITLE 427 <br />t <br />S5 <br />p <br />REd <br />UPCF UST -A Rev. (12/2007) <br />