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FIED PROGRAM CONSOLIDATED FO gfrj� <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION ❑ 1.NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400- <br /> (Checkooeitemonly) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE 99 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY d00 FACILITY ID q p _ <br /> (Agency Use Only) r h o I© a 1 - 1319 <br /> BUSINESS NAME(S...u FACiLrrY N$1 m DBA-rMi� Bwinev An 3. <br /> \R ZA Li tAop 1 <br /> BUSINESS SITE ADDRESS nu, CITY o 169. <br /> Soo c b 'C go h t�--0- Ls1NC [-A!�' <br /> FACILITY TYPE ❑ I.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 463. Is the facility located on Indian Reservation or 405. <br /> ❑ 3.FARM 0 4.PROCESSOR 26.OTHER Trust lands? [:]Yes PQ No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 40;. <br /> o crz2 20 / ly <br /> MAILING ADDRESS19 <br /> 403. <br /> / CITY 410 1 STATE 411. ZIPCODE 412- <br /> E c7 el, 1C4 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERA AME-_--". .______.__._.....__-... PHONE 4 <br /> Mw ed AM o1G r. ✓ (a°El )�7o-32g9 63q-r7yy <br /> 'MffitrNGADD 42s- <br /> T)C D S9Q4X C esokee- L N <br /> CITY 42&4 1 STATE 428-5 1 ZIPCODE 42M <br /> LOdI' CA 95 1/0 <br /> IV. TANK OWNER INFO TION <br /> TANK OWNER NAME: 414. PHONE 415. <br /> 0A11V1 a - (9t09) 99.2.-11-111 . <br /> MAILING ADDRESS 416, <br /> I <br /> CITY 413. 1 STATE as. ZIP ODE 419. <br /> Lo L) QA S>t/0 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420, <br /> ❑ 7.FEDERAL AGENCY do K NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK) HQ 44- 1 1 Call the State Board of Equalization,Fuel Tax Division,if there are questions. 431. <br /> VI.PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: ❑ 1.FACILITY OWNER ❑ 4.TANK OPERATOR 423 <br /> ❑ 3.TANK OWNER 99 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) 466 <br /> n/,A <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that the information provided herein is true,accurate and in full com liance with le al re uirements,E: <br /> APPLICANT SIGNATURE 1 i �> _.. DATE 7 / I I 2 424 PHONE -' a nz`. <br /> APPLICANT NAME(print) t/ I\i U M tl1 426. APPLICANTTITLE 424 <br /> V7 tl 14 201AIC1 <br /> e completed dOAP1Dli�C�l <br /> UPCF UST-A Rev.(12/2007) 1.14 i^(1NN1EFiTAL <br />