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RECEIVED UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-FACILITY INFORMATIWRONMENT L (DP'2t'facil�('j�hl TYPE OF ACTION1.NEW PERMIT El 5. 7.PERMANENT FACILITY CLOSURE 5.CHANGE OF INFORMATION 400. (Check one item only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT I: FACILITY INFORMATION TOT NU ER OF USTsA�T'7FACILITY 404. FACILITY ID# _ p2 (O (Agency Use Only) BUSINESS NAME(s-u FAcnm NANM or DBA-Doing 137 > /f J BUSINESS SITE ADDRESS � � 103.�. CITYZ � 10+ i FACILITY TYPE ❑ MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403. Is the facility located on Indi eservanon or 405. 3.FARM 4.PROCESSOR 6.OTHER Trust lands? ❑Yes No IL PROPERTY OWNER INFORMATION PROPERTY OWNER NAME _� 407, PHONE 409. w` S eq� 20 3��/�� - MAILIN ADDRESS 409. Ty 410 STATE 411 ZIP CODE 412. 1,2 t - ee513 z3 III.- TANK OPERATOR INFORMATION TANK OPERATOR NAME 429-1. PHONE 429-2 -2 MAILING ADDRESS az9-3 CITY 4294 STATE 429-5 ZIP CODE 429.6 �_ IV. TANK OWNER`INFORMATION TANK OWNER NAME 414. 1 PHONE _ 415. Fv7A A � D CITY ^ 417. STATF 419. ZIP CODE _ 419 e� - /3 OWNER TYPE: 1j 4.LOCAL AGENCYlDISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420 7.FEDERAL AGENCY NON-GOVERNMENT V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER Ty(-K)HQ 44_ Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421 VL PERMIT HOLDER INFORMATION 423 Issue permit and send legal notifications and mailings to: ❑ FACILITY OWNER C34.TANK OPERATOR L4 TANK OWNER ❑ 5.FACILITY OPERATOR 406 SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) VII.APPLICANT SIGNATURE CERTIFICATION: I tify that the information provided herein is true,accurate,and in full gomptiance with legal requirements. APPLICANTSIGNA DATE 424. PHONE 175 2 ✓ 426. APP�IC-_ T " 17 APPLICAN NA � /` � � �' UPCF UST-A Rev.(12/2007)