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# P* 233y <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUNDSTORAGETANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION �f / <br /> (One form per facility) <br /> TYPE OF ACI ION NEW PERMIT5.CHANGE OF INFORMATION 400. <br /> (Check one Ire„r+.drl ❑ ❑ 7.PERMANENT FACILITY CLOSURE <br /> ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBS USTs AT FACILITY 404. FACILITY ID# _ _ I. <br /> (Agency Use Only) <br /> BUSINESS (Some as Faci/lity�Nome or OBA-Doing Business As) 3. <br /> ���' �Gy�I Y'D ,Qi <br /> BUSINESS SITE ADDRESS 108. CITY 1w. <br /> FACILITY TYPE ❑ I.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403. Is the facility located on Indian Reservation or 405. <br /> [13.FARM [14.PROCESSOR 6.OTHER p-/D �C..& - Trust lands? ❑ 1.Yes ❑ 2.No <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 400, 1 PHONE 408_ <br /> MAILING ADDRESS 409, <br /> g3 <br /> CITY 410. 1 STATE 411. ZIP CODE 412. <br /> C <br /> M. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. PHONE 428-2. <br /> MAILING ADDRESS 428-3. <br /> CITY 4284. 1 STATE 4285. ZIP CODE 428-6. <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. 1 PHONE 415. <br /> MAILING ADDRESS 416, <br /> CITY 417. 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 <br /> - Call the State Board of Equalization,Fuel Tax Division,ifthere are questions. 421. <br /> VI. PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: ZRI.FACILITY OWNER ❑ 4.TANK OPERATOR 423. <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required for Rtbfic Agencies Only) 4%. <br /> VH.APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that the information provided herein is true accurate,and in full com lisace ith legal requirements. <br /> APPLICANT SIGNATURE DATE 424. wPHONE azs. <br /> APPLICANT NAME(print) 4z6. 1 APPLICANT TITLE 42v <br /> UPCF UST-A Rev.(12/2007)-1/2 www.unWom.org <br />