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11 <br />i AK t'La � <br />it-Zr• -i/ <br />UNIFIED PROGRAM CONSOLIDATED FORM <br />UNDERGROUND STORAGE TANK <br />OPERATING PERMIT APPLICATION — FACILITY INFORMATION <br />(One form per facility) <br />TYPE OF ACTION jdl. 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 />TOT NUMBER OF USTs AT FACILITY 404. <br />• <br />FACILITY ID # <br />_nL <br />L <br />`'f <br />� <br />(Agency Use Only) <br />BUS os FACRITY NAME or DBA — Doing Business As) 3 <br />i <br />Or L STO / <br />B SITEADbRESS 103. <br />CITY 104 <br />SO k <br />FACILITY TYPE ❑ 1. MOTOR VEHICLE FUELING ❑ 2. FUEL DISTRIBUTION 403. <br />Is the facility located on Indian Reservation or 401 <br />3. FARM [14. PROCESSOR Ar6. OTHER <br />Trust lands? ❑ Yes 9j:Ro <br />IL PROPERTY OWNER INFORMATION <br />PROPERTY OWNER NAME 407 <br />PHONE 408. <br />-1{o•MQg S, <br />MAILING ADDRESS 40' <br />10 ( V4ftt rl Lk. v L -,-JA <br />CITY 41q <br />STATE 411 <br />ZIP CODE 412 <br />L-bzs <br />C--� <br />?S- 2- <br />1111. <br />III. TANK OPERATOR INFORMATION __,—_ <br />TA. OPERATOR NAME 4128 -1. <br />-PH NE 428-2 <br />MAit — 428-s <br />__ -- <br />30j l.J <br />CITY-1294 <br />STATE 428-3 <br />ZIP COPE --,428-6 <br />CA <br />0 <br />I <br />IV. TANK OWNER INFORMATION <br />TANK OWNER NAME 414. <br />41 <br />,( 3 .-, L YCil/ <br />/PHONE <br />MAILING ADDRESS 4 1 6 <br />301 <br />CITY 417- <br />STATE 418- <br />ZIP CODE 41'1 <br />1 <br />1 <br />OWNER TYPE: ❑ 4. LOCAL AGENCY/DISTRICT ❑ 5. COUNTY AGENCY ❑ 6. STATE AGENCY 420 <br />❑ 7. FEDERAL AGENCY ;W. NON-GOVERNMENT <br />V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br />TY (TK) HQ 44_ 1 1Call 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: [11. FACILITY OWNER ❑ 4. TANK OPERATOR 411 <br />❑ 3. TANK OWNER X5. FACILITY OPERATOR <br />406 <br />SUPERVISOR OF DIVISION, SECTION, OR OFFICE (Required For Public Agencies Only) <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 STANATLJ4 <br />DATE 424 <br />PHONE 425 <br />it ) / 1 <br />0,7O Leo � - -2 w r <br />APPLICANT NAME (print)426. <br />APPLICANT TITLE 427 <br />S, Lticc ✓ <br />O WAJ <br />UPCF UST -A Rev. (1212007) <br />.4Z, <br />