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UNIFIED PROGRAM CONSOLIDATED FORAZ UNDERGROUND STORAGE TANK OPERATING PERD41T APPLICATION-FACILITY INFORMATION (One form per facility) TYPE OF ACTION .NEW PERMIT ❑ 5.CHANGE OF INFORMATION 400. (Check one item only) ❑ 3.RENEWAL PERMIT ❑ �'PERMANENT FACILITY CLOSURE ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT I. FACILITY INFORMATION TOTAL NUMBER OF USTs AT FACILITY 404. FACILITY ID# (Agency Use G'n!y) - BUSINESS NAME(SameTFA IL7NAMEorDBA-DoingBuuiussAs) 3 BUSINESS SITE ADDRESS 103 • -" -. 7A �.�,, ;e.._ .= 1 �! ,�:;l� L .- CITY � 1 /I �/ � ` ��r• 104. FALITY TYPE e I.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION ate' Is the facility located on Indian Reservation or aos. CI ❑ 3.FARM ❑ 4.PROCESSOR 6.OTHER Trust lands? ❑Yes ❑No II. PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407• PHONE 408• AILING ADDRESS ' `� L ! 1 / C' !(f MAILING 409. 7- CITY "0-d10• STATE 41)• ZIP CODE 412. III. TANK OPERATOR INFORMATION TANK OPERATOR NAME 1 428 • [PHONE- 428.2 4-1 772 MAILING ADDRESS 428-3 CITY 429.4 C•. `` STATE azss ZIP CODE 428.6 IV. TANK OWNER INFORMATION TANK OWNER NAME 414. PHO 4 415. 416. CITY 417• STATE 418. ZIP CODE 419. OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY a?o ❑ 7-FEDERAL AGENCY 8.NON-GOVERNMENT V. BOARD OF EQUALIZA LQN UST STORAGE FEE ACCOUNT NUMBER TY(TK)HQ 44- 3 S 4 " all the State Board of Equalization,Fuel Tax Division,if there are questions. 421. VI.PERMIT HOLDER INFORMATION Issue permit and send legal notifications and-mailings to: ❑ L FACILITY OWNER ❑ 4.TANK OPERATOR 423 ❑ 3.TANK OWNER 5.FACILITY OPERATOR SL PERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) 40-5. VII.APPLICANT SIGNATURE CERTIFICATION: I cerltit,that the information Provided herein is APPLICANT SIGNATURE true,accurate,and in full com fiance with le al re uirernent5. DATE j )4z4. PHONE425. AP?LICANT NAME(print) 4z6. APPLICANT TITLE �) �i � ^�1 C (1 y _ 427 CPCF UST-A Rev.(12;2007)