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a7, 93 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> o UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION - FACILITY INFORMATION { <br /> tone form per fucilit ) <br /> TYPE OF ACTION 1 . NE\4 PERMIT ❑ 5. CHANGE OF INFORMATION ❑ 7. PERMANENT FACILITY CLOSURE <br /> (Check one item only ) ❑ 3, RENEWAL. PERMIT- ❑ 6. TEMPORARY FACILITY CLOSURE ❑ 9. TRANSFER PERMIT <br /> L FACILITY INFORMATION <br /> TOTAL . NUMBER OF L`• STs A 'r FACILITY ^ ar'A FACILITY 1D f) <br /> (r (Agency Use Onlij <br /> i IIUSINESS NAME ( Same ms rACtt.rn NAME or DBA Dien,= Business AS) z <br /> I <br /> BUSHINESS S T1s ADDRESS cin' ) e.+ <br /> 0 329 S C r aA "N AVEitFS clout 01\1 <br /> FACILITY TYPIZ ❑ 1 . IMUFOR VEHICLE.. FUELING ❑ ?. FUEL DISTRIBUTION 103 is file lacihty located on In i in Reser atu)n or 40 <br /> ❑ 3. FARM ❑ 4. PROCESSOR ❑ G. OTHER Trust Ittngls? ❑ Yes 9po <br /> H. PROPERTY OWNERINFORMATION - <br /> PROPERTY OWNER NAME 407 PHONE 408 <br /> PE <br /> _ CrZjS [ N (0 �-bL tM6S ) NCl/Gvi2IPWET . i2 � Stb � 6Lf O47 <br /> ( MAILING ADDRESS 1:109. <br /> 1737, meogn120 / Sr <br /> CITY — 1110. STATE 411 ZIP CODF — 412 <br /> I s � c,� rvN <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAIt1E PHONE 429-' <br /> MAILING ADDRESS <br /> / 71z 1YRA? A, P0 IV S f <br /> CITY 4'-s-) STATE4-s 5 -ZIP CODE +=s-s <br /> dui �N �► Srzaq <br /> Al TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> KSWAt6 H10INGj !NCI- - , ( 570 ) 7 & q - 897c <br /> MAILING ADDRESS i1h 1 <br /> 17 2 �y/l� aN S r <br /> CITY 417 STATE 1111 . ZIP CODE 4113 <br /> Ut\'Ni iZ T'1' Pl:. ❑ 4 LOCAL AGENCY:DIstriumI ❑ 5. COUNTY AtirNCS'' ❑ 6. g0rATV' AGrNICY 4'--<' <br /> 7. FEDERAL AGENCY 8j 8. NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> Tl' (TKj 1 (Q 4 I- gall the State Board orEgtrtlizaaon. l=ucl "rax Division. if there are questions. a' t <br /> VI. PERMIT HOLDER INFORMATION <br /> Issue permit and Send legal notifications and mailina,Y to: i . FACILITY OWNERIMI-. "TANK OPERATOR -' <br /> *J . TANK OWNER ❑ 5 . FACILITY OPERATOR <br /> atx+ <br /> SUPERVISOR OF DIVISION, SECTION, OR OFFICE, ( Required For Public Agencies Only) <br /> _ VII. APPLICANT SIGNATURE <br /> C (: RTII>IC,1'l'ION : I certify that the information piamded herein is true, accut•atc, and in full cors li:utee swith legal requirements. <br /> i APPPLICAN4rSIGNA'11JRE DATE <br /> i APPI. ICANT NAMI: ( print ) 4-' <br /> APPLICANT"I I"ri_C: ='? <br /> t'1'CF CS"I'-A Rev. ( 1212007 ) <br />