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h�c MRECD'VEUNIFIED PROGRAM CONSOLIDATED FORMUNDERGROUNDSTORAGETANK OPERATING PERMIT APPLICATION-FACILITY INFORMATI VIRONAL VIRONMEN T YPE OF ACTION ❑ 1.NEW PERMIT ❑ 5.CHANGE OF INFORMATION El7.PERMANENT FACILITY CLOSURE 400heckoneitemonly) 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE El9.TRANSFER PERMIT d. FACILITY INFORMATION TOTAL NUMBER OF USTS AT FACILITY 404, FACILITY ID# 1. (Agency Use OnIY) BUSINESS NAME(S..FACILITY NAME or DBA-Dcingausinms As) 3. m U Q3 BUSINESS SITE ADDRESS �/A.��/�./I��.� �J 10J. CITY L 6-14 1 104. Yoo s, FACILITY TYPE pf I.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 4W. Is the facility located on Indian Reservation or 405. ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑Yes ❑No II. PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 401. PHONE 408. As 14ok- (24 ) 9V-17V9 MAILING ADDRESS (p qq 409. CITY 410. 1 STATk 411. ZIP CODE 41z. III. TANK OPERATOR INFORMATION TANK OPERATOR NAME 4za-1. PHONE 428-2 S Luvn9✓ (z� / ) Csll f MAILING ADDRESS 428-1 Soo CITY'C�, 42e4 1 STATE 4283 y)p tlp42e4 IV. TANK OWNER INFORMATION TANK OWNER NAME r 414. PHONE 415. MAILING ADDRESS 416. ve CITY 417. 1 STATE 418. ZIP CODE 414. OWNER TYPE: [14.LOCAL AGENCYIDISTRICT ❑ 5.COUNTY AGENCY ❑j 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 unit and send legal notifications and mailin s to: ❑ 4.TANK OPERATOR 423 pe ga g ❑ 1.FACILITY OWNER ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) 405, VII. APPLICANT SIGNATURE CERTIFICATION: I certify that the information provided herein is true,accurate,and in full compliance with legal re uirements. APPLICANT SIGNATURE DATE 424. PHONE ass. A51i - R 1< uM142 1 312 < I3 20 y APPLICANT NAME(print) 425. APPLICANT TITLE 427 UPCF UST-A Rev.(122007)