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• is <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK JUN 0 3 2015 <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION ty �Iql <br /> TYPE OF ACTION ❑ 1.NEW PERMIT ❑ 5.CHANGE OF INFORMATION PERMANENT FACIL _ o40TAACRI <br /> (Check one item only) ❑ 3 RENEWAL PERMIT ❑ 6.TEMPORARY FACiL,rf Y CLOSURE LJ 9.TRANSFER PERMIT Q, p�, <br /> I.,FACILITY INFORMATION o�� 7g .. <br /> TOTAL NUMBER OF USTs AT FACILITY 404. 1 <br /> FACILITY ID <br /> k (Agency Use Only) <br /> 3. <br /> BUSINESS NAME(Sema ss FACB.rrYNAbIEar DBA-Doin6 eusmess As) <br /> BUSINESS S ADD RESS 103. CIT c _ 104. <br /> � �� w . <br /> FACILITY TYPE E] 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403' Is the facility lojated on Indian Reservation or 405. <br /> d3.FARM 4.PROCESSOR R6.OTHER U14V-- Trust lands? ❑Yes ANo <br /> II. PROPERTY OWNER INFORMATION e <br /> PROPERTY OWNER NAME 4a�. <br /> PH �� 408. <br /> cA '/ i/o <br /> 4N <br /> MAILING ADDRESS <br /> CITY ` ® j 410. STATE 41I. ZIP C_QQDE ala <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. PHONE 428-2 <br /> 428-3 <br /> MAILING ADDRESS p ! t <br /> CITY vv " STATE 428.5 ZIP CODE axes <br /> C4 , ! <br /> V IV. TANK OWNER INFORMATION <br /> TANK OWNER�N.A�ME 414. PHONE � J/� 415. <br /> 7 N6 -!Q o f 41G <br /> MAILING ADDRESS <br /> f <br /> \" 418. ZIP CODE 419. <br /> CITY $p a 4n. STATE (� <br /> OWNER TYPE: E] 4.LOCAL AGENCY/DISTRICT El5.COUNTY AGENCY El6.STATE AGENCY <br /> 420, <br /> ❑ 7.FEDERAL AGENCY R,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. <br /> 421. <br /> VI.PERMIT HOLDER INFORMATION <br /> 421 <br /> Issue permit and send legal notifications and mailings to: [1I.FACILITY OWNER El4.TANK OPERATOR <br /> 03.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> 405. <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) <br /> VIL APPLICANT SIGNATURE <br /> CERTDTCATION%Pi t thein rotation provided herein is true,accurate, <br /> andin full comptah �a"l..reg uirem_e�nts?.PHO� <br /> APPLIC rjNATURE ® yI <br /> 4°2sr <br /> <- � TLE <br /> QkN,. t) <br /> UPCF UST-A Rev.(1212007) <br />