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r—Av o.237,�q <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION 1.NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 40e_ <br /> (Check one item only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404, FACILITY ID# T' <br /> (Agency Use Only) <br /> BU SSNA (S..1AC=NAMEor DBA-Do.1Buo..As) 3. <br /> tI GD a edQ <br /> BUSINESS SITE DRE^S gym. CITY ta. <br /> %LJ-7(p L.� 1 <br /> FACILITY TYPE ❑ 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 40J' Is the facility located on Ind py Reservation or 405. <br /> ❑ 3.FARM ❑ 4.PROCESSOR 6.OTHER Trust lands? C]Yes {ffNo <br /> H. <br /> PROARTY OWNER INFORMATION <br /> PROPERTY OWNER NAME407 PHONE aos. <br /> Lina ola <br /> MAILING ADDRESS 409. <br /> 7 kt 0.nn <br /> CITY 410 1 STA 411- ZIP CODE 412 <br /> g5aLio <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 426-1, 1 PHONE 429-2 <br /> SUnn2 ( ) <br /> MAILING ADDRESS 428-3 <br /> CITY 42&4 STATE 42s-5 ZIP CODE 42M <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 1 PHONE 415, <br /> MAILING ADDRESS 416. <br /> CITY 417 1 STATE OTs. ZIPCODE 419. <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420- <br /> ❑ 7.FEDERAL AGENCY 90 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 1 1 Call the State Board of Equalization,Fuel Tax Division,ifthere are questions. 421_ <br /> VI.PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: 2-rFACILITY OWNER ❑ 4.TANK OPERATOR 420 <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: I certify that the information provided herein is true,accurate,and in full compliance with legal requirements. <br /> APPLICANT SIGNATURE DATE 424 PHONE 426 <br /> APPLICANT NAME(print) 426 APPLICANT TITLE 427 <br /> UPCF UST-A Rev.(12/2007) <br />