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UNIFIED PROGRAM CONSOLIDATED FORM 77 2 �, <br /> UNDERGROUND STORAGE TANK L Z <br /> OPERATING PERMIT APPLICATION— FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION ❑ I.NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400' <br /> ICherk one item only) JN 3,RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 4p0' FACILITY ID# I 1 1 1 1 1 1 1 1. <br /> 2- 1 (Agent use On(y) <br /> BUSINESS NAME(Same as Facilitv Name or DBA-Doing Business.I sl J. <br /> ?- J,&fZ-F&P,7T t.MSD Inc[. MMt-I nrPr <br /> BUSINESS SITE ADDRESS 10)_ CITY iM. <br /> �a fo B,n c Cave I..f Sn ct:.r e,.f <br /> FACILITY TYPE ❑ 1.MOTOR VEHICLE FUELING [12.FUEL DISTRIBUTION 401 Is the facility located on Indian Reservation or +os. <br /> 3.FARM Q 4.PROCESSOR E9 6.OTHER Trust lands? ❑ I.Yes ,N 2.No <br /> IL PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 4% <br /> C Ur- <br /> MAILING ADDRESS 4W <br /> CITY 410 1 STATE 411, ZIPCODE 4F1 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 42S I I PHONE 4=92- <br /> MAILING ADDRESS rr- ,- 42s-4 <br /> W <br /> CITY 4284 STATE +'-s^ ZIPCODE 42sg <br /> Sthuc CAE I as <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE +13. <br /> f-I.C NrSh1 (2n ) 4S►— o'-la.S <br /> MAILING ADDRESS J16 <br /> Q-0. 606. -(9`1 <br /> CITY 417 1 STATE 418 1 ZIPCODE Oro - <br /> STO f-2/-7-B-.( C-a '11� 2 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 4'-0 <br /> ❑ 7.FEDERAL AGENCY Rl S.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(1K)HQ 44- O 3 2- 1 3 I 'S7 t I 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: ❑ 1.FACILITY OWNER ❑ 4.TANK OPERATOR <br /> ,1 <br /> JK 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required(or Public Agencies Ondv) 406 <br /> VII.APPLICANT SIGNATURE <br /> ER lCA Ice fy that the information provided herein is true accurate and in full compliance with legal reqgi ts. <br /> A PLIC SI T E DATE +24 1 PHONE '� +=' <br /> Zdt ) yt4 <br /> APPLICANT NAME(print 4'-6. APPLICANT TITLE tA. <br /> 427 <br /> WGA <br /> UPCF UST-A Rev.(12/2007)-1/2 www.unidoes.org <br />