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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PEP041T APPLICATION - FACILITY INFORMATION (One form per facility) TYPE OF ACTION NEW PERMIT (Check one item only) ❑ S. CHANGE OF INFORMATION ❑ 7. PERMANENT FACILITY CLOSURE 43" ❑ 3. RENEWAL PERMIT ❑ 6. TEMPORARY FACILITY CLOSURE ❑ 9. TRANSFER PERMIT I. FACILITY INFORMATION TOTAL NUMBER OF USTs AT FACILITY 404' FACILITY ID is 1 _J. (Agency Use On/)) BUSINESS NAME (s!r� nFA Il-rryNA-MorDBA— DoingBwinessAs) / 3. BUSINESS SITE ADDRESS` '�^� E 103. CITY 104. FACILITY TYPE y,0' 1. MOTOR VEHICLE FUELING ❑ 2. FUEL DISTRIBUTION 403. 405 Is the facility located on Indian Reservation or ❑ 3. FARM ❑ 4. PROCESSOR ❑ 6. OTHER Trust lands? ❑ Yes ❑ No II. PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407, PHONE 408. MAILING ADDRESS ' L L)\ �� I� � C � /' 1�` 1 •/ �' (i (t i 409 CITY Co. STATE 411. ZIP CODE 412 III. 'TANK OPERATOR INFORMATION 7 ANK OPERATOR TAME 1 428-1. PHONE /{ /1 428-2 !BAILING ADDRESS ( y �� Z)) L/ 1 4284 I STATE 429.5 7_IP CODE L-`� 426-6 IV. TANK OWNER INFORMATION TANK OWNER NAME 414 PHO als NAILING ADDRESS 416 CITY 417, STATE 418, ZIP CODE 419 OWNER TYPE: ❑ 4. LOCAL AGENCY/DISTRICT ❑ 5. COUNTY AGENCY ❑ 6. STATE AGENCY 420. ❑ 7. FEDERAL AGENCY 8. NON.GOVERNMENT V. BOARD OF EnUALIZAIiQN UST STORAGE FEE ACCOUNT NUMBER TY (TK) HQ 44- 3 3 4 4-7 c—T.— all the State Board of Equalization, Fuel Tax Division, if there are questions. 421 J VI. PIPERMIT HOLDER INFORMATION Issue permit and send legal notifications and mailings to: ❑ 1. FACILITY OWNERI , ❑ 4. TANK OPERATOR 423 ❑ 3. TANK OWNER �5 FACILITY OPERATOR SL PERVISOR OF DIVISION, SECTION, OR OFFICE (Required For Public Agencies Only) 405, V71I. APPLICANT SIGNATURE CERTIFICATION. I certify that the information provided herein is true, accurate, and in full com liance with le al requirements. APPLICANT SIGNATURE DATE 414. PHONE 425 AP?LICAN 'NAME (punt) y/ 1 4z6 APPLICANT TITLE1 z (• ( 1 \ 1 427 b � L`PCF UST -A Rev. (12'2007)