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C3' yfItIV-7 <br /> {M A/ <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION—FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION ❑ 1.NEW PERMIT S.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400- <br /> (Chxt one men only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> L FACILITY INFORMATION <br /> TOTAL NUMBr <br /> F USTS AT FACILITY 401 FACll.ITY ID# <br /> (eseaer u.�onlrl �o � <br /> BUSINESSNAME(�a FACa,rrY NAI4E«rBA-ooina Bmoeo As) <br /> 3 <br /> ,) T ^ LUTK C-r- PLAZT <br /> BUSINESS SITEADDRESS -t02 Frov� tae- RoamCITY <br /> 9 / Pan <br /> FACILrN TYPE L MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 401' Is the faclity located on Indian Reservation or nos. <br /> 3.FARM 4.PROCESSOR Q 6.OTHER Trust lands? ❑Yes ff No <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTYQWNER NAME 4m. PHONE eoa. <br /> L .0 6 t <br /> MAILING ADDRESS Ny <br /> CITY � � 410. STATE all. <br /> �--AJ"Ir 1 q ZIP CODE aiz <br /> J 1=� q ,40701 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATORNAME 4x8-1. PHONE nae <br /> N 0:27) 591 R 1 ) 1 <br /> MAILING ADDRESS 4xas <br /> CI 4u 1 STATE 428-5 <br /> ZIP CODE azee <br /> C--A <br /> IV. TANK OWNER INFORMATION <br /> TA?fKPWNERNAME 414. PHONE ns. <br /> MAILING ADDRESS � ale. <br /> )lJ <br /> C 412. STAT$I/rL�, aa. ZIP CODE �O� 419. <br /> OWNER TYPE: [14.LOCAL AGENCYIDISTRICT 7t❑�r5.COUNTY AGENCY ❑ 6.STATE AGENCY 4W- <br /> Elfon <br /> 7.FEDERAL AGENCY 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- — Q Call the State Board of Equalization,Fuel Tas Division,if there are questions. 421_ <br /> VI.PERMIT HOLDER INFORMATION <br /> Issue permiland senq,q�l notifications and mailings to: 3K1.FACILITY OWNER ❑ 4.TANK OPERATOR 4M <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVIPION,SECTION,OR OFFICE(Required For Public Agencies Only) 40fi. <br /> VIL APPLICANT SIGNATURE <br /> CERTIFICATION: I cerci that the information provide herein is cru accurate and in full compliance with 1 requirements. <br /> ?EPLICANT SIGNATUffDATEI-�97— 424 PHONE <br /> LICANT NAME(prim4xa. APPLICANT T� D --4 <br /> C--!W <br /> Nk L <br /> UPCF UST-A Rev.(12!2007) P' r " t <br />