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0 a <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF;i�t�emonly) <br /> N ❑ 1.NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400. <br /> (Check one ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE, ❑ 9.TRANSFER PERMIT <br /> 1. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404' FACILITY ID 4 G J� /� D 1' <br /> (Agency Use Only) T U V <br /> BUSINESS NAME(Same as FACILITY NAME or DAB` Doing Business As) 3. <br /> LC4, Iv� l <br /> BUSINES SITE ADDRESS I �^ 103 Cr� / �'IAR MA"P104, <br /> ') � � Ioa. <br /> FACILITY TYPE 1.MOTOR VEHICLE FUELING ❑ 2.FUAL DISTRIBUTION 403' Is the facility located ' $ a ion or aos. <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑Yes UIN <br /> UNTY <br /> II. PROPERTY OWNER INFORMATION HEALTH DEPARTMENT <br /> PROPERTY OWNER NAME 407 PHONE 408 <br /> IG�O S - P <br /> MAILING ADDRESS 409 <br /> CITY 410. STATE 411 ZIP CODE 412, <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. PHONE 428-2 <br /> MAILING ADDRESS 428-3 <br /> C TY 4284 STATE 428-5 ZIP CODE 428-6 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414, 1 PHONE 415, <br /> AEIDIZESS <br /> 416. <br /> CITY 417. STATE 8. 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- i� I C1 I q I S I&I IT 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 423 <br /> ❑ 3.TANK OWNER 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Publ is Agencies Only) 406 <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: 1 certify that the information provided herein is true,accurate,and in full cont liance with legal requirements. 4 <br /> APPkICA,NT SIGNATURE DATE f 424. <br /> AVPICANT;P\E(print) 426. APPLICANT TITLE% � ( 427 <br /> UtJ� <br /> UPCF UST-A Rev.(12/2007) <br />