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r..t <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION- FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION ❑ I.NEW PERMIT ❑ 5.CHANGE OF INFORMATION `-k 7.PERMANENT FACILITY CLOSURE' 400- <br /> (Check one item only) ❑ 3.RENEWAL PERMIT <br /> ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION f'A Ob ZZ-q.,j 4W <br /> 77 <br /> TOTAL NUMBER OF USTs AT FACILITY 404 FACILITY ID p <br /> (Agency Use Only) <br /> BUSINESS NAME(Same as Facillty Name or DBA-Doing Business As, 3. <br /> ME-r• N / 4'ir <br /> BUSINESS SITE ADDRESS 01 <br /> (� 1 103. CITY 1 . <br /> 77 <br /> P dLln W4 C <br /> FACILITY TYPE El1.MOTOR VEHICLE FUEL NG Ell FUEL DISTRIBUTION 403. Is iiia-facility located on Indian Reservation or 405. <br /> 3.FARM 0 4.PROCESSOR .OTHER I Trust lands? ❑ I.Yex=iZ2.No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 40r_ PHONE 409 <br /> t„ vn ^ La A- a50-z - 1 <br /> MAILING ADDRESS n L 409 <br /> - ���V' ri J✓�.G COL.r J <br /> CITY ••7 410- STATE 4t]- ZIP CODE 41'- <br /> mor',4 /�, I G�4 c:-Y3 <br /> III. TANK OPERATOR INFORMATION <br /> TAMC OPERATOR NAME 429-1. PHONE 429-2 <br /> MAILING ADDRESS _ 428-3 <br /> CITY 4284. STATE 428-5 ZIPCODE 428-6 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415. <br /> 4 L.---sem ) <br /> MAILING ADDRESS 416. <br /> CITY 417 1 STATE 41& ZIP CODE 419. <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY azo. <br /> ❑ 7.FEDERAL AGENCY _ �8.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: --*i1=1.FACILITY OWNER ❑ 4.TANK OPERATOR 423 <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required for Public Agencies Only) 406_ <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 424 PHONE - 425. <br /> APPLICANT NAME(print) 426. APPLICANT TITLE ,r,_�7 427 <br /> UPCF UST-A Rev.(12/2007)-I/2 www.unidocs.org <br /> CV <br /> lX V <br />