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�3 !� UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-FACILITY INFORMATION 3)k - f 1 TYPE OF ACTION ❑ 1.NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACIL[ OSI-RE 1M1' (Chock one itemonly) ❑ g RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT I. FACILITY INFORMATION TOTAL NUMBER OF USTs AT FACILITY I °04- FACILITY ID 4 1_ (Agency Use Only) Q BUSINESS NAME(Sao,or FACILITY NAME or DBA-Doing Bminas As) S. C' i 1 BUSINESS SITE ADDRESS ilia- CTY iaa_ s L s . FACILITY TYPE ❑ I.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 40J' Is the facility located on Indian Reservation or 4os. El 3.FARM Ej 4.PROCESSOR IL 6.OTHER Trust lands? ❑Yes JONO II. PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 41n_ PHONE 408. 0. Z LIN DRESS '' AAI 409, {/ y♦ ° CITY 410. 1 STATE 411, 1 ZIP CODE 412. M W 9533 III. TANK OPERATOR INFORMATION TANK OPERATOR NAME 4zx-1. PHONE 4zx-z MAILING ADDRESS 428-3 CITY 4284 STATE 429-5 1 ZIP CODE 428a IV. TANK OWNER INFORMATION TANK OWNER NAME 414. PHONE 415. L kL MAILING ADDRESS 416. CITY 417. 1 STATE 418. ZIPCODE 419. OWNER TYPE: [144.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420, ❑ 7.FEDERAL AGENCY ❑ 8.NON-GOVERNMENT V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY(TK)HQ 44- Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421. VI. PERMIT HOLDER INFORMATION Issue permit and send legal notifications and mailings to: .FACILITY OWNER ❑ 4.TANK OPERATOR 423 ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) 006 VII.APPLICANT SIGNATURE CERTIFICATION: 1 certify that the in rmation provided herein is true,accurate,and in full compliance with legal requirements. APPLICANJ SIGNATURE _ DATES I 424 PHONE � APPLICANT4u. NAME(print) 4� APPLICANT TITLE zt rn_r v w G t/a} r UPCF UST-A Rev.(12/2007)