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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK7io' <br /> OPERATING PERMIT APPLICATION- FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION L NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 40. <br /> (Check one item 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# 1' <br /> (Agency Use Only) <br /> BU INESS NAME Same as Facility Name or DBA-Doing Business As) 3. <br /> t n o Mess r)see L-1 - VGA 01 0 I N eW <br /> BUSINESS SITE DRESS 1 1071 CITY 104. <br /> �f7,/V1 VCS c� O <br /> FACILITY TYPE ❑ I.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION Is the facility located on Indian Reservation or 405. <br /> ❑ 3.FARM ❑ 4.PROCESSOR X 6.OTHER I L C Trust lands? ❑ 1.Yes 92.No <br /> H. PROPERTY OWNER INFORMATION <br /> P PERTY OWNER NAME40. PHONE 4aa 6D <br /> a>t l �al/a4^'o 209 5 /Z <br /> MAILING ADDRESS 409. 0 <br /> 2 <br /> urz 6 flawmew �2 <br /> C 410. STATE 41, ZIPCOD41 <br /> ?1,4 � 7/S-11,?6A LV <br /> III. TANK OPERATOR INFORMATION �.Ib <br /> TANK OPERATOR NAME 4284, PHONE 428-2. <br /> MAILING ADDRESS 428-1 <br /> CITY 4284, STATE 428-5. ZIP CODE 428-6. <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> 'r `E: <br /> MAILING ADDRESS 416. <br /> CITY 412 1 STATE 418. ZIP CODE 419. <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY S.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: 9-I.FACILITY OWNER ❑ 4.TANK OPERATOR 423' <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required jor Public Agencies Only) 406. <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: 1 certify t -tion provided herein is true,accurate and in full compliance with legal requirements. <br /> APPLICANT SIGNATURE DATE/ q i/'� 424 PHONE 425, <br /> APPLICANT NAME(print) IL 426. APPLICANT TITLE -JV �1 427 <br /> Nava P-/o V wn4P ' <br /> UPCF UST-A Rev.(12/2007)-1/2 w .unldocs.org <br />