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y. <br /> UNIFIED PROGRAM CONSOLIDATED FORM IAN 2 0 2015 <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORRO NM Q <br /> TYPE OF ACTION 1.NEW PERMIT ❑ 5.CHANGE OF INFORMATION +� L1 <br /> ❑ 7.PERMANENT FACILITY CLOSURE <br /> (Check one Rem only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT --TA D 510 TJS Ih''�I)$ <br /> L FACILITY INFORMATION �p 0 714Lf- <br /> TOTAL NUMBER OF USTs AT FACILITY 401 FACILYfY ID# 1. <br /> �C �j UiJ OA/� (Agency Use Only) — <br /> BU$ ESSNAME(Sameu FACZLOO'Ah¢or DBA-Dpn ausines Ar <br /> 8 ) <br /> ifc.�N7 GoT /ze of,-V£o,/ i,ZE Sy 7o G.r Cr LOJI <br /> BUSINESS SITE ADDRESS "a CITY is <br /> SovT,s� <br /> FACILITY TYPE ❑ 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 409' Is the facility located on Indi eservadon or 405. <br /> El 3.FARM 4.PROCESSOR 6.OTHER Trust lands? ElYes No <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 4m PHONE 409. <br /> T� GO�� zo S �oS <br /> MAIL]NO ADDRESS <br /> FQ 13n>L <br /> 409. <br /> TY mo. STATE 411. <br /> ZIP CODE 412 <br /> CC <br /> 50Z -,,,/-i9/o <br /> III. TANK OPERATORINFORMATION <br /> TANK OPERATOR NAME 4294. 1 PHONE 428-2 <br /> %vn1K ofJnJr - .tKidl0 S/ T� ( > <br /> MAILING ADDRESS 428-3 <br /> CITY 4284 STATE 7ZIPCODE 428-6 <br /> N. TANK OWNER INFORMATION <br /> TANK OWNER NAME4u. PHONE 415. <br /> �d / ;? <br /> MAILtis'faA KESS 416. <br /> CITY ©Q 42 STATE_ 418. ZIP CODE 419, <br /> �i <br /> OWNER TYPE: 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY . <br /> ❑ 6.STATE AGENCY 420 <br /> ❑ 7.FEDERAL AGENCY ❑ 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST 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 <br /> Issue permit and send legal notifications and mailings to: ❑ FACILITY OWNER ❑ 4.TANK OPERATOR <br /> v <br /> TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) 406' <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: 1 certify that the information provided herein is true,accurate,and' full coni liance with legal requirements. <br /> APPLICANT SIGNATURE DATE/_/ /5, 424. 1 PHONE 429 <br /> APPLICA NAM - 426 2 dr / <br /> APPLICANT TI� 4n <br /> C- /li9i✓�9G Fes( <br /> UPCF UST-A Rev.(1212007) <br />