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DECEIVED <br /> OCT 4) 6 2016 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK Ems,/�R�NTAL HEALT <br /> OPERATING PERMIT APPLICATION-FACILITY INF8NA T��F��T <br /> 6 te�'AeT(acility> <br /> TYPE OF ACTION1.NEW PERMIT ❑ 5.CHANGE OF INFORMATION °m <br /> (Check one keen only) ❑ PERMANENT FACILITY CLOSURE <br /> ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NU ERn OF UST3 AT FACILITY °p°' FACILITY ID C <br /> `� � (Ageney Use Only) <br /> BU$ E$$NAMEISvn<a FACJL NAE DBA—Dane Busomev A, 3. <br /> BUSINESS SITE ADDRESS IID. CITY IN <br /> S 331) <br /> FACILITY TYPE ❑ 1.MOTOR VEHICLE FUELING 2.FUEL DISTRIBUTION amIs the faility located on Indi ervadon or4os_ <br /> .FARM 0 4.PROCESSOR 6.OTHER Trust lards? ❑Yes No <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 1 PHONE 4m. <br /> ,e <br /> MAILING ADDRESS 409. <br /> Y�' 4110 1 ST(f% °N. ZIPCOD4M <br /> fIII. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 423-I, PHONE 423.2 <br /> MAILING ADDRESS 42&3 <br /> CRY 4234 STATE +Z5-5 ZIP CODE °zea <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 1 PHONE 415 <br /> MAILING <br /> CITY ,5 / 4I r. STB1�T� +Is. ZIP CODE / 419. <br /> OWNERTYPE: jj4 LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420 <br /> Lj 7.FEDERAL AGENCY CfEK'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,ifthere are questions. i21' <br /> VI.PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and Imilings to: ❑ FACILITY OWNER El 4.TANK OPERATOR 423 <br /> TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) °m <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 42+ 4n_ <br /> es �6o (7,9G S>� <br /> A ICAN NAh�F.� 426 APPL15ANT Tqla , 427 <br /> UPCF UST-A Rev.(12!300'!) <br /> 10 <br />