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UNUTED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK CA <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION �y <br /> (One form per facility) <br /> TYPE OF ACTION ❑ 1.NEW PERMIT 015 CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400' <br /> (Check one item only) ❑ 3 RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> 1 <br /> TOTAL NUMBER OF USTs AT FACILITY 4(X. I FACILITY D# _ <br /> 3 (Agency Use Only) - <br /> BUSINE$$NAME(amen FACadtY NAwcrDBA-Doing Biuhemm) <br /> ttJINS CO�NTDey S7A-T/OM <br /> BUSINESS SITE ADDRESS 103. CITY IN <br /> 1111 G-. Ice iGM I ASF <br /> 405 <br /> FACILITY TYPE 1.MOTOR VEHICLE FUELING r] 2.FUEL DISTRIBUTION 403' is the facility located on Indian Reservation or <br /> 3.FARM n 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑Yes PkNo <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 4m. PHONE aoe. <br /> ILt- PA-.1DN672 1AI Vii Mg-mT e, 08 �0AC l Lt <br /> .�. <br /> MAILING ADDRESS <br /> M l lV e Q1?O7" /- <br /> Cffl <br /> 4iSTA <br /> 4t �COD � 412. <br /> 3 <br /> in. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 4ze-t. PHONE 428.2 <br /> ghm6ep S�� ti I �sti GILL cU ) god -9t �t <br /> 428.3 <br /> 1 ADDRESS <br /> ,111 KL(� M A� L� <br /> K6 r^i <br /> CITY O I 4z STATE 418-5 ZIP CODE 42" <br /> q E 2- L4 <br /> IV. ANK WNERINFORMATION <br /> TANK OWNER NAME I„ 7 e at4. PHONE acs. <br /> MAILING ADDRESS 416 <br /> CITY 411. STATE 418. ZIP CODE 419. <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY PC 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGEFEEACCOUNT NUMBER <br /> Tom.(TK)HQ 44 Call the State Board of Equalization,Fuel Tax Division,if there are questions. 4x1. <br /> �I 3 vi.PERMIT HOLDER INFORMATION <br /> 4x3 <br /> Issue pemlit and send legal notifications and mailings to: ❑ 1.FACILITY OWNER 4.TANK OPERATOR <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> 406. <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION:V cerci that th formstlon pmvided herein is trae accurate,and in full coin Iaum with le requirements. <br /> APPLICANT SIGNA �/ 0 424. 'Min <br /> HONE Q- Lf <br /> 01/q DATE { 1 % D O 0�" /q 4 1 fr, <br /> APPLICANT NAME(print ax6. APPLICANT EJ N1 go 13 <br /> UPCF UST-A Rev.(17121187) , ) 0 <br /> ,/ <br />