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UNIFIED PROGRAM CONSOLIDATED FORM dW <br /> UNDERGROUND STORAGE TANKz31 <br /> OPERATING PERMIT APPLICATION—FACILITY INFORMA ON <br /> (One form per facility) <br /> TYPE OF ACTION ❑ L NEW PERMIT ❑ 5.CHANGE OF INFORMATION • <br /> (Check one imm only) ❑ 3.RENEWAL PERMIT ❑ 7.PERMANENT FACILITY CLOSURE On <br /> ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 400- FACILITY ID N <br /> (Agency Use Only) <br /> BUSINESS NAME( Fgc¢,m RnnrEorDeq-wings,, <br /> /C n NA /// <br /> BUSS SSITEADDRESS 103 <br /> CITIY �, <br /> FACILITY TYPE 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION °0J' Is the facility located on Indian Reservation or 405. <br /> 3.FARM 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑Yes No <br /> IL PROPERTY OWNER INFORMATION <br /> PROP OWNER NAME <m. PHONE roe. <br /> M xli 0'1-34 h - <br /> MAILIN DDRESS <br /> CITY <br /> ��• 410- STATE +11 ZIP CODE 412, <br /> HLTANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME PHONE 42s-2 <br /> MAILIN ADDRESS <br /> Z <br /> �- , 428-3 tN7 /-f-'/�'xG�� <br /> CITY 4ze.4 STATE 423-5 ZIP CODE 4285 <br /> + `9 SSC; <br /> IV. TANK OWNER INFORMATION <br /> TANK NAME , 414. PHONE - <br /> 415. <br /> MAILLNP ADDRESS <br /> (WV) p4a2 -S77Cp <br /> Z �p <br /> /L,�rJ� <br /> CITY N 417 1 STATE 413. ZIP CODE 916. <br /> 419. <br /> C SSD <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- Call the State Board of Equalization,Fuel Tax Division,if there are questions. 021. <br /> VI.PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: ❑ L FACILITY OWNER ZI423 <br /> 4.TANK OPERATOR <br /> 14 3.TANK OWNER 9,5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) acs. <br /> VIL APPLICANT SIGNATURE <br /> CERTIFICATION: 1 certif tha e i tormatian rovided herein is <br /> APPLICANT SIGNA true accur a and in full com fiance with le al requirements <br /> DAPI U / Zc�10 424, PHONE <br /> O Ijs <br /> APPLICANT NAME(print _ 4zs. APPLICANT TI <br /> p e5e�p� <br /> f v <br /> 427 <br /> `' ... <br /> UPCF UST-A Rev.(12/2007) <br /> 0 <br />