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UPCF UST -A Rev. (12/7007) <br />r NIFIED PROGRAM COINSOLIDATEE W R <br />UNDERGROUND STORAGE TANK <br />OPERATING PERMIT APPLICA'T'ION - (FACILITY INFORMA'T'ION <br />(One form per facility) <br />TYPE OF ACTION ❑ L NEW PERMIT ❑ S. CHANGE OF INFORMATION ❑ 7. PERMANENT FACILITY CLOSURE 499. <br />(Clieck one iteln only) 3. RENEWAL PERMIT ❑ 6. TEMPORARY FACILITY CLOSURE ❑ 9. TRANSFER PERMIT <br />I. FACILITY INFORMATION <br />TOTAL NUMBER OF USTs AT FACILITY 414 <br />1 FACILITY ID <br />t' <br />(Agency Use Only) <br />BUSINESS NAME (Same as FACILITY NAME or DBA -Doing Businm As) 3. <br />PI "C} L L, L'I-- (�_ <br />BUSINESS SITE ADDRESS <br />Z'�1► His <br />IBI, <br />r It aC <br />CITY 1°4. <br />QI IOLs: -ryc <br />FACILITY TYPE 1. MOTOR VEHICLE FUELING ❑ 2. FUEL DISTRIBUTION 903 <br />Is the facility located on Indian Reservation or 4m5' <br />❑ 3. FARM ❑ 4. PROCESSOR 6. OTHER <br />Trust lands? ❑ Yes tallo <br />H. PROPERTY OWNER INFORMATION <br />PROPERTY OWNER NAME 407. <br />PHONE 408. <br />mp� <br />1 ("?19 <br />.;,w-- <br />MAILING ADDRESS 409 <br />7,70 tJ. G.S&11 {'' U_ 0 <br />CITY 410. 1 <br />411. <br />STATE 411, <br />ZIP CODE 411. <br />'] ggl� 411. <br />M. TANK OPERATOR INFORMATION <br />TANK OPERATOR NAME 428-1_ <br />nmRL mord e nc, <br />PHONE 4212 <br />U/N )PIV.201 <br />MAILING ADDRESS 428-3 <br />N. Ncsktil -Aux <br />CITY as Tu 428-4 STATE 4'-8-5 ZIP CODE '620j 42a-6 <br />ixLil_ <br />IV. TANK OWNER INFORMATION <br />TANKOWNERNAME 414.PHONE <br />MnC ��� L� <br />4 11. <br />c 1 . 099 z`�& <br />MAILING ADDRESS 416- <br />CITY 4n. STAT" 411, ZIP CODE 419_ <br />�all�S TK <br />_ <br />OWNER TYPE: r❑ 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 HOLDER INFORMATION <br />Issue permit and send legal notifications and mailings to: 0 1. FACILITY OWNER ❑ 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 cer ' that the information rovided herein is true accurate and in full com p lienee with le al requirements. <br />APPLICANT SIGNATURE <br />ATE 424 <br />�2tc Z_t?G�i <br />PHONE 425. <br />f 5S ('7 <br />APPLICA T AME(prim) t J126 <br />PPLICANTTITLE j 42) <br />UPCF UST -A Rev. (12/7007) <br />