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MT' 101[c L <br /> %oKIFIED PROGRAM CONSOLIDATED FOI+m4 <br /> UNDERGROUND STORAGE TANK 4(1011z' <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION 10-4[ty Y�`- <br /> (One font per fact tty) <br /> TYPE OF ACTION 01.NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 4U0. <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 404 FACILITY ID# _ <br /> (Agency Use Only) c/ <br /> BUSINESS NAME(sme m rwcanv r4wr.¢m oaw-omos B.w.> <br /> 9�1 <br /> BUSINES SITE ADDRESS tn3. CITY IM. <br /> 1340 6vCo.j QrPe -� <br /> FACILITY TYPE [31T.MOTOR VEHIC E FUELING C12.FUEL DISTRIBUTION 003' Is the facility located on Indian Reservation or 405. <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑Yes ❑No <br /> IL PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME aor. PHONE Ops. <br /> c LLC- X40- 2-687, <br /> MAILING ADDRESS <br /> -1511S <br /> CITY <br /> 410. STATE 411. ZIP CODE 4tz. <br /> CIA 95377 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAM 428-1. PHONE M -7 425-3 428-2 <br /> AILING ADDRESS <br /> 3I / G <br /> CITY 428-4 STATE 428-5 ZIP CODE 42s <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414, PHONE 425. <br /> VP LL ('11w ) 8�oa '-17 <br /> MAILING ADDRESS /s 416. <br /> CITY 4n. STATE. 418. ZIP CODE 419. <br /> T C 53 77 <br /> OWNERTYPE: ❑ 4. OCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> L? + Q I Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421 <br /> VL PERMIT HOLDER INFORMATION <br /> Issue pern tt and send legal notifications and mailings to: ❑ 1.FACILITY OWNER '.d 4.TANK OPERATOR 423 <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 true accurate and in full compliance with legal requirements. <br /> APPLICANTDATE 424. 1 PHONE 425. <br /> APP NT NAME(print) 426. APPLICA ITLE t n <br /> UPCF UST-A Rev.(1712007) <br /> COiRIetOd <br />