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RECEIVE <br /> UNIFIED PROGRAM CONSOLIDATED FORMUNDERGROUND STORAGE TANK <br /> ���5 _✓ i <br /> OPERATING PERMIT APPLICATION-FACILITY INFO RMA ({RpNM 'g7 <br /> TYPE OF ACTION1.NEW PERMIT ❑ 5.CHANGE OF INFORMATION <br /> (Check one item only) ❑ 7.PERMANENT FACILITY CLOSURE <br /> ❑ 3.RENEWAL PERMIT. ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION .Fp o p J Z7jpq ! <br /> TOTAL NUMBER OF USTS AT FACILITY 40a' FACILITY ID# �h <br /> �fL.l r DIVA (Agency Use Only) — S <br /> BUS ESSNAME(Svncaz FACLLI'fY NAA¢oreap-pang B,ninm As) <br /> ffcA�7' GoT �i� o�IVF'' i�E Sy�o G.r or' <br /> BUSINESSSITEADDRESS 103. CITY 1w <br /> FACILITY TYPE ❑ 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403' Is the facilitylocated on India eservadon or 405. 2-1� <br /> El 3.FARM [14.PROCESSOR 6.OTHER Tr33st lands? ❑Yes No / <br /> II; PROPERTY OWNER INFORMATION 17I P <br /> PROPERTY OWNER NAME 407. PHONE ane. <br /> MAILM ADDRESS +a9 <br /> 3o <br /> TY 410. STATE411. ZIPCODE 412. <br /> l Com, 50�2 -/5/o <br /> IIL TANK OPERATOR INFORMATION- <br /> TANK OPERATOR NAME 42g-1. PHONE 428-2 <br /> MAILING ADDRESS 4e9-3 <br /> CITY 4284 STATE 428-5 ZIP CODE 42" <br /> PV: TANK OWNER INFORMATION <br /> TANK OWNER NAME +u. PHONE 415. <br /> i <br /> 49t'_ 610,J l <br /> MAILBiCaA RESS 416. <br /> CITY +n. STAT ve. ZIP CODE 419, <br /> OWNER TYPE: 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY0 <br /> ❑ 6.STATE AGENCY 42 <br /> ❑ 7.FEDERAL AGENCY ❑ 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATIONUST STORAGE FEE ACCOUNT NUMBER <br /> i <br /> TY(TK)HQ 44- Call the State Board of Equalization,Fuel Tax Division,if there are questions. 428. <br /> VL PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: ❑ FACILITY OWNER ❑ 4.TANK OPERATOR <br /> TANK OWNER OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) 4 <br /> 06' <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that the information provided herein is true,accurate and in fuH compliance with legal requirements. <br /> APPLICANT SIGNATURE DATE/_/0 ✓ PHONE <br /> `/64 <br /> 4u. <br /> APPLICAN NAM 4z6. APPLICANT TI 427 <br /> lCOJ f /lJi9r✓9GF�( <br /> UPCF UST-A Rev.(12/2007) <br /> it <br />