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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION ❑ L NEW PERMIT ❑ 5.CHANGE OF INFORMATION <br /> (Check one item only) ❑ 7.PERMANENT FACILITYCLOSURE °m' <br /> ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY ao4. <br /> FACILITY ID# 1 <br /> (Agency Use on <br /> BUSINESS N/�1E(Smne m FACn.IIY NAAfl:or DBA-piling&¢i..As) <br /> ]. <br /> 6 f�.a� >°n/,c /G / <br /> BU INESS SIT ADDRESS 1 103 CIT <br /> 04. <br /> v�Y /J I /✓ <br /> FACILITY TYPE ❑ I.MOTOR VEHICLE FUELING 0"£FUEL DISTRIBUTION 403' <br /> Is the facility located on Indian Reservation or 405. <br /> 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑yes F],NR <br /> PROPERTY OWNE NAME II. PROPERTY OWNER INFORMATION <br /> 407 PHONE 408 <br /> MAILING AgDRESS <br /> aoz. <br /> CITY 2 <br /> i 410 STATE 4a ZY ODE <br /> l //� 41z. <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATO NAME 4284. PHONE <br /> e^I, 429-2 <br /> MAILING ADu S 71 J -J'✓/� <br /> 428.3 <br /> CITY <br /> S4( ��,,tt 4284 STATE 428-5 ZH.CO E _ 42M <br /> e L- L .d-o- SL/S <br /> TANK OWNER N IV. TANK OWNER INFORMATION <br /> 414. PHONE 415. <br /> MAILING ADDRES <br /> 416. <br /> CITY 417. STA:/9 419. ZIP CODE alv. <br /> AOro / /C <br /> OWNER TYPE: ❑ 4.LOCAL 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 /> 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.FACILITYOWNER <br /> ❑ 4.TANK OPERATOR 423 <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) 406. <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: 1 eer ' tha't the information provided herein is true,accurate,and in full com liance with le al re uiremeots. <br /> APPLICANT SIGNATURE DATE 424. PHONE 415. <br /> APPLIC AM (print) 4+.6. ZS-App ANT TITLE <br /> 427 <br /> �/L C //"•r,r•f V� <br /> UPCF UST-A Rev.(12/2007) r7 I_. <br />