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Q - :: h4c1 <br /> _..JNIFIED PROGRAM CONSOLIDATED#"*MKQ/p p <br /> UNDERGROUNDSTORAGETANK <br /> OPERATING PERMIT APPLICATION- FACILITY INFORMATION <br /> (One fore per facility) <br /> TYPE OF ACTION ❑ I.NEW PERMIT ❑ 5.CHANGE OF INFORMATION 4m. <br /> (Check one item only) ❑ 7.PERMANENT FACILITY CLOSURE <br /> ❑ 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 /> Z - <br /> (Agency Use Only) <br /> BUST ESS NAME(S4mem FACILITY NAME.or DBA-Doing Business As) 3. <br /> BUSINESS SITE ADDRESS 103 <br /> 1•` 11 1�• ti�lsk.e.11 �'90C' cITY,bczllas:-rX 104 <br /> FACILITY TYPE 1,MOTOR VEHICLE FUELING403' a0s. <br /> ❑ 2.FUEL DISTRIBUTION Is the facility located on Indian Reservation or <br /> ❑ 3.FARM ❑ 4.PROCESSOR JK 6.OTHER Trust lands? ❑Yes �4 No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 408. <br /> �o( LSC, ll4 x'74 11 ► <br /> MAILING ADDRESS �y <br /> X711 nl. +Swxl� f`9t)0 <br /> CITY 410, STATE 411. ZIP CODE 412. <br /> '^ !tis TX X5187 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1, PHONE 4ag-2 <br /> GG HRe, 0_)C' (21 <br /> MAI LING A DDRESS .428-3 <br /> 7_111 . Ha�kelr �� <br /> CITY 4284 STATE 428-5 1 ZIP CODE 428 <br /> C�oi�laS T1r _ _ ��J���� <br /> IV. TANK OWNER INFORMATION <br /> TANKOWNEI{NAME 414. PHONE 415,. <br /> MAILING ADDRESS 416. <br /> 27r 1 N• Nas�e�.i �'��0 , <br /> CITY �J�QC 417. 1 STP-" � 418. ZIPCODE 419. <br /> OWNERTYPE: �❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420 <br /> ❑ 7.FEDERAL AGENCY 'M 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421. <br /> VI. PERMIT IIOLDER INFORMATION <br /> Issue permit and send legal notifications and tnailin s to: 1.FACILITY OWNER 423 <br /> Pe g g '� ❑ 4.TANK OPERATOR <br /> ❑ 3.TANKOWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) 406. <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I certKy that the informationprovided herein is true accurate and in full compliance with legal requirements. <br /> APPLICANT SIGNATURE DATE 424 PHONE 4255 <br /> �12� 1Ak .a"C/ [5-� C6t' <br /> APPLICA T AME(print) 426. APPLICANT TITLE \ 427 <br /> in L nCh <br /> UPCF UST-A Rev.(12/2007) - <br />