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!iXA' 13 — O3 <br /> x'00 231a�'� �R d 551337 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> � Ilv <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION—FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION ❑ 1.NEW PERMIT ❑ 5.CHANGE OF INFORMATION xk7.PERMANENT FACILITY CLOSURE d00- <br /> (Check one uem 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# t. <br /> (Agency Use Only) <br /> BUSINESS NAME(Same as Facility Name or DBA—Doing Business As) 3_ <br /> In �1^h C-10 <br /> Q�hq 44, <br /> BUSMESS ITE ADDRES Ex O 5 Im8 CITY y <br /> 5;Lt-C P4 <br /> FACILITY TYPE ❑ I.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403- Is the facility located on Indian Reservation or 4m5_ <br /> ❑ 3.FARM ❑ 4.PROCESSOR >R6.OTHER Trust lands? ❑ I.Yes ;B� 2.No <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME ••,, 401 PHONE 408. <br /> l 9-'1r <br /> MAILING ADDRESS (� 4w <br /> Ll . <br /> i l S tii <br /> CITY 410 STATE 411, 1 ZIP CODE 412_ <br /> a T J <br /> HI. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 438-1 PHONE 428-2. <br /> S � <br /> MAILING ADDRESS 428-3- <br /> CITY 4284 1 STATE 428-5, ZIP CODE 42e-s, <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415 <br /> MAILING ADDRESS 616 <br /> CITY 417 STATE Ota. ZIPCODE 419 <br /> OWNER TYPE: [14.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 430 <br /> ❑ 7.FEDERAL AGENCY .NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44_ 1 1 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: T'-49Z71.FACILITY OWNER ❑ 4.TANK OPERATOR 423' <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required far Public Agencies Only) 406 <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that the information provided herein is true accurate and in full compliance with legal requirements. <br /> APPLICANT SIGNATURE DATE 424 PHONE 425. <br /> APPLICANT NAME(print) 426- APPLICANT TITLE 422 <br /> UPCF UST-A Rev.(122007)-1/2 ww%.unidocs.org <br />