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Ili )1' 10 / 249 GZ(!2 <br />UNIFIED PROGRAM CONSOLIDATED FORM rpl o`o�r D� <br />UNDERGROUND STORAGE TANK <br />OPERATING PERMIT APPLICATION - FACILITY INFORMATION <br />(One form per facility) <br />TYPE OF ACTION ❑ 1. NEW PERMIT ❑ 5. CHANGE OF INFORMATION ❑ 7. PERMANENT FACILITY CLOSURE 400 <br />(Check one item only) JZ 3. RENEWAL PERMIT ❑ 6. TEMPORARY FACILITY CLOSURE ❑ 9. TRANSFER PERMIT <br />I. FACILITY INFORMATION <br />TOTAL NUMBER OF USTs AT FACILITY 404 <br />FACILITY ID # <br />(Agency Use Only) <br />BUSINESS I%I E$S NAME (Same a5 FACILITY NAME oCA—r -Doing Business � () n ^ n � D J 3 <br />S GCS N �6 OiJ&Ife4�l�//V) (C/ ✓S ll <br />BUS ESS SITE ADDRESS S � 103 <br />CITY ioa. <br />FACILITY TYPE F11. MOTOR VEHICLE FUELING 02. FUEL DISTRIBUTION 403. <br />Is the facility located on Indian Reservation or aos. <br />❑ 3. FARM ❑ 4. PROCESSOR ❑ 6. OTHER <br />Trust lands? []Yes Z'No <br />II. PROPERTY OWNER INFORMATION <br />PROPERTY OWNER NAME 407.PHONE <br />408 <br />�o s <br />409. <br />MAILING ADDRESS <br />L <br />IV <br />[TY 410 <br />STATE 411. <br />ZIP CODE 412. <br />D D <br />III. TANK OPERATOR INFORMATION <br />TANK OPERATOR NAME 428-1PHONE <br />428-2 <br />s uS <br />( <br />MAILING ADDRESS 428-3 <br />CITY 428-4 <br />STATE 428-5 <br />ZIP CODE 428-6 <br />1 <br />N� <br />o io Y� <br />IV. TANK OWNER INFORMATION <br />TANK OWNER NAME 414 <br />_14 Z <br />PHONE 415 <br />475 3f96 <br />S Uj <br />MAIL G DRESS a16. <br />Waoy <br />CITY 4n. <br />STATE 418. <br />IVIT_ <br />ZIPCODE 419. <br />D?OyD <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- 1 1 1 1 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: El❑ I. FACILITY OWNER 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 />VII. APPLICANT SIGNATURE <br />CERTIFICATION: 1 certify that the information provided herein is true, accurate, and in full compliance with legal requirements. <br />AAPTNATURE <br />DATE 424_ <br />0 <br />PHONE 41` <br />77n i-ozo'2s <br />AP LICANT NAME (print) 426 <br />APPLIVANT TITLE 427 <br />UPCF UST -A Rev. (12/2007) <br />