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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 ❑ I.NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400. <br /> (Chad one item only) ❑ 3.RENEWAL PERMIT <br /> ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9,TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 604' FACILITY IDH _ 1 ITT-T t- <br /> (Agency Use Only) <br /> BUSINESS NfA�ME(Same as Facility Name or DBA-Doing B/usinneem AsJ a <br /> �"'G n --WsY�YI�Ci <br /> BUSINESS SITE ADDRESS IF3. CITY io4. <br /> r Fa_ 4 S Z-,--) <br /> FACILITY TYPE ❑ I.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403. Is the facility located on Indian Reservation or 405. <br /> ❑ 3.FARM ❑ 4.PROCESSOR Ad.OTHER Trust lands? ❑ I.Yes ❑ 2.No <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 409, <br /> N I � <br /> MAILING ADDRES 409. <br /> CI n 410. STATE� 411. ZIP CODE 412. <br /> HI. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 418-1. PHONE 429-1 <br /> n irocn i s n (2Op) `�$ 3- til off <br /> MAILING ADDRESS 4zS-3 <br /> 4dCtA9 IRI r'� (��If'�' <br /> CITY 4284. STATE 429-5. ZIP CODE 4294. <br /> a-- C <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME //'s 'I J. 4i4. PHONE 4u. <br /> O - Y`KMt�n -C�$'�T1.tai'710 ( ) Qtr 727 <br /> MAILING ADDRESS Ota <br /> CITY 417. 1 STATE 418 1 ZIP CODE 419 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <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 Equalimuon,Fuel Tax Division,if there are questions. 421 <br /> VI. PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to. ❑ I.FACILITY OWNER ❑ 4.TANK OPERATOR 423. <br /> V 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 434, 1 PHONE 421 <br /> APPLICANT NAME(print) 426. APPLICANT TITLE 4'-7 <br /> UPCF UST-A Rev.(12/2007)-1/2 www.unidoes.org <br />