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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 ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 44p <br /> (Chack.meat 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# <br /> r. <br /> (Agency Use Only) ,AJ <br /> BUSINESS NAME(S®e r FACnl1V NAMEor DOA-Doi,Brum Aa) ). <br /> S <br /> BUSINESS SITE ADDRESS ta5. CITY toy, <br /> 2q71 <br /> FACILITY TYPE ❑ 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DIS BUTTON Is the facility located on Indian Reservation or 105' <br /> 3.FARM 0 4.PROCESSOR Q 6.OTHER Trust lands? ❑Yes ❑No <br /> IL PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME +mPHONE moa <br /> So w ' e Si 2`i ?S /S y K <br /> MAILING ADDRESS W. <br /> ggO r Yn o CIT-de <br /> CITY U <br /> ata I STc� aATE all. ZIP CODE z <br /> qsz� Z <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME az%i. PHONE aze-z <br /> uY ee ( ) $ 1- <br /> MAILING ADDRESS 428-3 <br /> 2 Q3 Cfln, ori Q f <br /> CITY azae STATE 428-5 ZIP CODE azss <br /> sJ C <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME ata. PHONE au. <br /> u W)YJJ er <br /> MAILING ADDRESS 4K <br /> \YC <br /> CITY l atz. 1 STATE ata. ZIP COD `_ ) 419. <br /> OWNER TYPE: [14.LOCrALLAAGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ .6..STATE AGENCY 4". <br /> ❑ 7.FEDERAL AGENCY ❑ 8.NON-GOVERNMENT <br /> TION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TIC)HQ 44 Call the State Board of Equalization,Fuel Tax Division,if there are questions. 42L <br /> ---- HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: ❑ 1.FACILITY OWNER <br /> 214.TANK OPERATOR 4v <br /> ❑ 3.TANK OWNER ❑ 5-FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agenoica Only) 106' <br /> VH.APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that the information provided herein is true accurate,and in full coat Bance with 1 requirements. <br /> APPLICANT SIGNATURE DATE - / aza. PHONE <br /> HO E au. <br /> APPLICANT NAME(print) am. APPLICANT TITLE a <br /> eY <br /> UPCF UST-A Rev.(IV2007) <br />