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FIED PROGRAM CONSOLIDATED FOw -7 701 <br /> UNDERGROUND STORAGE TANK ENVIRONMENT HEALTH <br /> o4dAOPERATING PERMIT APPLICATION-FACILITY INFORMATROMInvnabry, <br /> kcha; S> <br /> TYPE OF ACTION ❑ 1.NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400. <br /> (Check ane 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 /> h rle (Agency Use Only) <br /> BUSINESS NAME( arse ee FACMM NAME.,DBA-Doing Business As) 3' <br /> C 6257-00 G 111 5T7Y-77aAl l/U3 / <br /> BUSINESS SITE ADDRESS to3. CITY <br /> z 4v >nlo& Sr �f4. <br /> FACILITY TYPE �Kl.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403. Is the facility located on Indian Reservation or 405. <br /> t3.FARM El4.PROCESSOR [16.OTHER Trust lands? []Yes <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAMEa°�. PHONE 408' <br /> G'es}zv d/ery/e � Siad <br /> MAILING ADDRESS 409' <br /> CITY <br /> 410. STATE au. ZIP CODE � 4a. <br /> LSSLt. �lti/ Zi /tl <br /> IH. TANK OPERATOR(INFORMATION <br /> TANK OPERATOR NAME 4284. pHONE 428-2 <br /> MAILING ADDRESS 428-3 <br /> see �I T <br /> CITY 4284 STATE 428'5 ZIP CODE 428.6 <br /> IV. TANK OWNER INFORMATION <br /> TANKOWNERNAME /� ! ata. PHONE 415. <br /> MAILING ADDRESS 416. <br /> San �s <br /> e <br /> CITY 417. 1 STATE 418. ZIP CODE 419. <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY JX8.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: 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 /> VH.APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that the Information provided herein is true accurate,and in full compliance With legal requirements. <br /> APPLICANT SIGNATUREDATE 4]A. PHONE 415. <br /> y-27-76s`� <br /> APPLICANT NAME(print) 426. APPLICANT TITLE 427 <br /> 7jch�ri`s /�i� Coh LlFh✓G� yl!/,�-i✓�"G�/l <br /> UPCF UST-A Rev.(12/2007) <br />