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UPCF UST -A Rev. (12/2007).1/2 www.unidocs.org <br />FIED PROGRAM CONSOLIDATED FO IN <br />UNDERGROUND <br />(t <br />STORAGE TANK 1� <br />OPERATING PERMIT APPLICATION- FACILITY INFORMATION 1_1 <br />; <br />(One form per facility) ( JJ/.;, <br />(" <br />TYPE OF ACTION ❑ 1. NEW PERMIT ❑ 5. CHANGE OF INFORMATION ❑ 7. PERMANENT FACILITY CLOSURE 400. <br />(Check one irem cn(v) <br />3. RENEWAL PERMIT ❑ 6. TEMPORARY FACILITY CLOSURE ❑ 9. TRANSFER PERMIT <br />I. FACILITY INFORMATION <br />TOTAL NUMBER OF USTs AT FACILITY 409' FACILITY ID q I. <br />_ <br />e (Agency Use 0: l D <br />BUSINESS Mi ME (Same as Fac ity Name or DB - Doing Business As) 3 <br />l <br />l/ice v G s -r W ,t/ 039� <br />BUSINESS SITE ADDRESlos. 1a4. <br />GIf11GCl <br />� G/' !l � tJh <br />FACILITY TYPE �I. MOTOR VEHICLE FUELING ❑ 2. FUEL DISTRIBUTION 603. <br />Is the facility located on Indian Reservation or a05. <br />3. FARM Q 4. PROCESSOR 6.OTHER <br />Trus[ lands? ❑ i. Yes'2. No <br />R. PROPERTY OWNER INFORMATION <br />PROPERTY OWNER NAME 407 <br />,o Ldoleswlr <br />PHONE 408. <br />MAILING ADDRESS 409 <br />Time <br />cck& <br />CITY 410. <br />STATE 411. <br />ZIP CODE V 2 1-7 41z. <br />q <br />III. TANK OPERATOR INFORMATION <br />TANK OPERAT NAMEe 42&1. <br />a I �K <br />PHONE, 4293. <br />r�1 - rNAiS <br />( Z, 1 2 7xS-T <br />MAILING AD ESC <br />24 /e ,� 42&3. <br />I/(Y, <br />CITY T/i%/C <br />4284, <br />STATE 428-5. <br />ZIP CODE 42". <br />W. TANK OWNER INFORMATION <br />TANK OWNER NAME J ua. <br />PHONE 415. <br />MAILING ADDRESS 41k <br />CITY 417, <br />STATE 418. <br />ZIP CODE 419. <br />OWNER TYPE: ❑ 4. LOCAL AGENCY/DISTRICT ❑ 5. COUNTY AGENCY Q 6. STATE AGENCY 420 <br />❑ 7. FEDERAL AGENCY ❑ 8. NON-GOVERNMENT <br />V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br />TY (TK) HQ 44- loll letl( Call the State Board of Equalization, Fuel Tax Division, if there arc questions. 421 <br />VI. PERMIT HOLDER INFORMATION <br />Issue permit and send legal notifications and mailings to: 423. <br />Pe eg g ❑ 1. FACILITY OWNER 4. TANK OPERATOR <br />❑ 3. TANK OWNER ❑ 5. FACILITY OPERATOR <br />SUPERVISOR OF DIVISION, SECTION, OR OFFICE (Required for Public Agencies Only) 4on. <br />VII. APPLICANT SIGNATURE <br />CERTIFICATION: I cerdfv that the infarmaH evaded herein is true <br />accurate and in full compliance with legal requirements. <br />APPLICANT SIGN <br />p azo. <br />�/ PHONE 425. <br />_ �an <br />APPLICANT NAIVE(print 426. <br />cher dGt`- <br />ppp CANT TLE <br />UPCF UST -A Rev. (12/2007).1/2 www.unidocs.org <br />