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i <br /> 1/ <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> STORAGE TANK <br /> OPERATING PERMIT APPLI <br /> UNDERGROUND <br /> TION-FACILITY INFORMATION <br /> JUN 0 3 2015 <br /> TYPE OF ACTION VI <br /> ❑ 1.NEW PERMIT ❑ S.CHANGE OF INFORMATION PERMANENT FACIL 4 <br /> (Check ane item only) ❑ 3 RENEWAL PERMIT D4 OTAACAI <br /> ❑ 6.TEMPORARY FACILITY CLOS URE f3 9.TRANSFER PERMIT QOt <br /> T I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AFACILCTY 4e1. <br /> a FACILITY ID k 1, <br /> 't (Ag' Use Only) - <br /> BUSINESS NAME(Store u PACa.I'1'Y NAbfE er DBA-Doing Business N) <br /> 3. <br /> BUSINESSLTE`gpDRESS <br /> (dG cJ ` "✓Y� CIT; 104. <br /> FACILITY TYPE ❑ I,MOTOR VEHICLE FUELING <br /> ❑ 2.FUEL DISTRIBUTION 403' Is the facility located on Indian Reservation or 465. <br /> 103.FARM 4.PROCESSOR gr6.OTHER k_0 Tmst lands? ❑Yes No <br /> PROPERTY OWNER <br /> II. PROPERTY OWNER INFORMATION <br /> NAME <br /> c. <br /> /^ / a07. PHONE\1P \` '�Sry/f 408. <br /> MAILING ADDRESS Ip y6 y9µ <br /> s <br /> CITY W . �r w`Gl/e/V �-`c/✓✓vA 4c9. <br /> `'e�'AG S f 410. STATE 411. 'ZIP C DE 411p <br /> TANK OPERATOR <br /> III. TANK OPERATOR INFORMATION 77 <br /> NAME - <br /> 4zs-I. PHONE 428-2 <br /> MAILING ADDREASS` � �t1 1 <br /> CITY <br /> JVk � 4;8-4 1 STATE a2a•s ZIP CQOg- 4286 <br /> ZO4 <br /> TV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> cs j f 1/0 <br /> MAILING ADDRESS <br /> 9 416. <br /> CITY 417. 1 STATE418. ZIP CODE 419. <br /> �1y li✓VLG�� �'- O <br /> OWNER TYPE: 114.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY R,8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TIC)HQ 44- 1 1 Call the State Board of Equalization,Fuel Tax Division,if then:are questions. T2_ <br /> VL PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: ❑ I.FACILITY OWNERau <br /> ❑ 4.TANK OPERATOR <br /> 03.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) 406, <br /> VIL APPLICANT SIGNATURE <br /> CERTIFICATION:-I-reffli thelin rmation rovided herein is true,accurate,and in full co m liance with le al re uirements. <br /> APPL[CAN�SYGNATURE / DATE, 77 +2+ MO+NE 425. <br /> .AEE/LI/G,A t) 426. APPLIIC NI TI'I LE G zS _ 3 4z0 <br /> UPCF UST-A Rev.(12/2007) <br /> L <br />