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U <br /> UNIFIED PROGRAM CONSOLIDATED FORM 04 V <br /> uNDERGROUNDSTORAGETANK <br /> T7 <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMA ON <br /> (One funn 'facility) <br /> Z <br /> TYPE OF ACTION 11 1.NEW PERMIT ❑ 5,CHANGE OF INFORMATION 7.PERMANENT FACILITY CLOSURE p'/� <br /> (Check one item only) 171 3.RENEWAL PERMIT M 6.TEMPORARY FACILITY CLOSURE TRANSFERPERMIT ki <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER USTs AT FACILITY FACILITY ID# le <br /> (Agency Use Only) <br /> 13USINESSNjkW(S�nFA�N�MDBA-Doing B. .m) <br /> 103. CITY <br /> BUSINESS SITE ADDRESS <br /> --403. Is the facility located on <br /> FACILITY TYPE F1 I.MOTOR VEHICLE FUELING El 2.FUEL DISTRIBUTION Trust lands? 0 Yes 0 <br /> 3.FARM El 4.PROCESSOR E] 6.OTHER <br /> Ilr7PROPERTY OWNER INFORMATION .". III <br /> 07. PHONE <br /> PROPERTY OWNER NAME _7.2 70 <br /> r,-q,?Ce.r r <br /> 149 -7-270 <br /> MAILING ADDRESS <br /> CITY 60 vo/, 410. STATE all. ZIP CODE 411 <br /> 1-o ; CA, 95:21"0 <br /> M. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 4z 1. PHONE 423.2 <br /> 428-3 <br /> MAILING ADDRESS <br /> CITY STATE 428.5 ZIP CODE 4234 <br /> IV. TANK OWNER INFORMATION <br /> TANKOWNFRNAME 414. PHONE 415. <br /> 416. <br /> MAILING ADDRESS <br /> CITY 411. 1 STATE 418. I ZIP CODE 419. <br /> OWNER TYPE: rl 4.LOCAL AGENCY/DISTRICT F1 5.COUNTY AGENCY ❑ 6.STATE AGENCY 410. <br /> El 7.FEDERAL AGENCY 16.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER 421. <br /> TY(TK)HQ Call the State Board of Equalization,Fuel Tax Division,if them are questions. <br /> VI.PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and nuailings to: El 1.FACILITY OWNER 0 4.TANK OPERATOR 423 <br /> 3.TANK OWNER E] 5.FACILITY OPE3*OR <br /> 406. <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) <br /> VII.APPLICANT SIGNATURE <br /> - <br /> CERTIFICATION: I certify that the Information rovided herein its true,accurate,and in fun compHance with le gg mquir- ants. <br /> - <br /> APPLICANT GNATUREDATE// <br /> FhQNh <br /> ( <br /> APPLICANT NAME(print) 426. APPLICANT TITLE an <br /> 4110 <br /> UPCF UST-A Rev.(12/2007) <br />