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0 46 RECEIVE <br /> UNIFIED PROGRAM CONSOLIDATED FORM 1914 <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFO404NM <br /> TYPE OF ACTION 1.NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILrrY CLOSURE 4m' "' <br /> m <br /> (Check one iteonly) ❑ y RENEWAL PERMIT- ❑ 6.TEMPORARY FACR-rrY CLOSURE ❑ 9.TRANSFER PERMrr -TA Q 5.2-D 7-75 )IInP <br /> I. FACILITY INFORMATION 4�-Pr O O <br /> TOTAL NUMBER OF USTS AT FACILITY 009' FACILITY m# _ _ 1 <br /> &dt u J/ 04v4 (Agency Use Only) <br /> BUSINESS NAME(Smearncarrct+nho:eroaA-DoinsBadnessM) <br /> �cAN7- Z-DT /7 o' ;,/"a r-/?3? or' LDJ /V V <br /> BUSINESS SITE ADDRESSC1TY <br /> '! �Ow cllellD eE <br /> FACILITY TYPE ❑ 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 4m' Is the facility located on Indiati.Reservation or �40'y, <br /> Trust lands? [I Yes No �n Ill7� <br /> 3.FARM 4.PROCESSOR 6.OTHER <br /> R PROPERTY OWN ERINFORMATION" 3�Igl <br /> PROPERTY OWNER NAME 40PHONE 408 <br /> MAIL[N ADDRESS 409' <br /> 306)6 <br /> TY 410 STATE 411. ZIP CODE 412. <br /> HI. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. PHONE 42e-2 <br /> MAILING ADDRESS 428-3 <br /> CITY 4284 1 STATE 4U.5 I ZIP CODE 4284 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415 <br /> T� a ' &'ed l -2�49s <br /> MAILMADDRESS 416. <br /> // od <br /> CITY 4n. STAT�, 418. ZIP CODE 419. <br /> 40Cid • S'i /- / /O <br /> OWNER TYPE: ofg4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420 <br /> ❑ .FEDERAL AGENCY ❑ S.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATIONUST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421. <br /> VI.PERMIT HOLDER INFORMATION 415 <br /> Issue permit and send legal notifications and mailings to: ok.FACILITY OWNER ❑ 4.TANK OPERATOR <br /> 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: I certify that the information provided herein is true,accurate and in full com fiance with legal requirements. <br /> APPLICANT SIGNATURE DATE 4z4. PHONE ass. <br /> /-4 1 (20f <br /> &LICANI NAMEJ*fffty 427 <br /> G.�.c � / RDJ� � /l�ik✓�9GF�( <br /> UPCF UST-A Rev.(1212007) <br />