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UNIFIED PROGRAM CONSOLIDATED FORM A3 <br /> UNDERGROUND STORAGE TANK T-pip($7(epi J <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 /> (Check one item only) ❑ 3,RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 4a4, FACILITY ID# <br /> (Aget Use Onfy) OL <br /> BUSINESS NAME(same mFACn.nYNA orr)BA-Bomg Buei mAe) <br /> r,-r4 rr S <br /> BUSINESS SITE ADDRESS )03. CITY )w. <br /> FACILITY TYPE ❑ L MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 003' Is thefacility located on Indi Reservation or 405' <br /> 3.FARM 4.PROCESSOR EI6.OTHER Trust lands? El Yes Q9,No <br /> - II.-PROPERTY OWNER INFORMATION - <br /> PROPERTY OWNER NAME �7 40I PHONE 408' <br /> !`4itce r lu�r�s/ e , en ti/« X09 368 -7.290 <br /> MAILING ADDRESS 409' <br /> lv 6CJ b/t k 5 -F,-ea* <br /> CITY 410. STATE 4)). =CODE atx. <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 4za-i. pp )NE 428-2 <br /> s�•NE c ) <br /> MAILING ADDRESS 428-3 <br /> CITY 4x84 STATE 428-5 ZIP CODE 428-s <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> SFFrnE ( ) <br /> MAILING ADDRESS 416 <br /> CITY 417. 1 STATE 41e. ZIP CODE 419. <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY �teS.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TI()HQ 44- 1 1 Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421. <br /> VI.PERMTI'HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: 423 <br /> ❑ 1.FACILITY OWNER ❑ 4.TANK OPERATOR <br /> �3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> 406. <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that the information provided herein is tru accurate,and in full com Itance with legal requirements. <br /> APPLICANT GNATURE DATE// 424. PHONE ass. <br /> G� aez�i3 p/4 37.t �s3s' <br /> APPLICANT NAME(print)14x6. APPLICANT TITLE 4n <br /> belts Onf'rw cr%V2 <br /> UPCF UST-A Rev.(12/2007) <br />