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UNIFIED PROGRAM CONSOLIDATED FORM <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) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY dod. FACILITY ID# _ _ f <br /> (Agency Use Only) <br /> BU$IN IS NAME(grare u FACR NAME or DaA-Doing Boainaa N) 3. <br /> BUSINESS SITEADDRESS t05. CITY IN <br /> A6-0 /j- c <br /> FACILITY TYPE ❑ 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 003Is the facility Iota on Indian Reservation or 405. <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑Yes Q No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 4.8 <br /> OL' J O - 0 <br /> MAIM ADDRESS 4ay. <br /> CITYU 410, 1 STATE 411, ZIPCODE 412 <br /> f c 3 ` <br /> HL TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 425-1- PHONE 42e-2 <br /> MAILING ADD SS dzea <br /> by <br /> CITY 4zs 4 STATE 4zs-5 ZIP CODE r 1 457 <br /> C <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 4i4. PHONE 415. <br /> 54nAv (S—/C) ) L - <br /> MAILING A13DRESS U Ola <br /> CITYU 417 STATE 419. ZIP CODE 419. <br /> J-3 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCYIDISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 4201 <br /> ❑ 7.FEDERAL AGENCY ❑ 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- C ( .�- "11 Call the State Board of Equal u,ahon,Fuel Tax Division,if there are questions. I- <br /> VI.PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to. ❑ I.FACILITY OWNER ® 4.TANK OPERATOR 433 <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) 40 <br /> VII. APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that the info,motion provided herein is true accurate,and in full compliance with legal requirements. <br /> APPLICAN N TURF DATE424 PHONE azs. <br /> O U 20 �/ ,re <br /> APPLICA AME riot) 426APPLICANT TITLE 427 <br /> e <br /> UPCF UST-A Rev.(122007) t completed <br />