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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-FACILITY INFORMATION (One form per facility) TYPE OF ACTION ❑ L NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 4M (Check one item only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT I. FACILITY INFORMATION TOTAL NUMBER OF USTs AT FACILITY d.a FACILITYID# (Agency Use Only) BUSINESS NAME(Same a<FaCurry NA or DBA-Doing Bonn- l BUSINESS SITE ADDRESS 103. CITY 104. 40 L q a FACILITY TYPE ❑ 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403. Is the facility located on Indian Reservation or 405. ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑Yes ❑No II. PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407 PHONE 409. ;Ttiti L KaMa 2-(d 3`ib MAILING ADDRESS 409. o L wfLo CITY 410- STATE 411 ZIP COD 412, C X533 0 III. TANK OPERATOR INFORMATION TANK OPERA"1'012 NAME 428-1 PHONE 428-2 L m (�� ) (011-6391. MAILING ADDRESS 428-3 LAT4110f X04 CITY 4284 STATE 428-5 ZIP CODE 428-6 1- i i2 0 f C✓-} Q 5317 IV. TANK OWNER INFORMATION TANK OWNER NAME 414. PHONE 415. -I A k AjAi, S ( XI )(012-�39 6 MAILING ADDRESS 416. l- WF QR CITY 11 Q 417. STATEC� 418. ZIP CODE 953X 419. OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. ❑ 7.FEDERAL AGENCY A 8.NON-GOVERNMENT V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY(TK)HQ 44- CII the State Board of Equalization,Fuel Tax Division,if there are questions. 021' 6 O DE ORMATION Issue permit and send legal note cation n Ings to: K I.FACILITY OWNER ❑ 4.TANK OPERATOR 423 ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) 406' VII. APPLICANT SIGNATURE CERTIFICATION: I cern that the information provided herein is true,accurate,and in full com liance with legal requirements. A SIGNA DA aza. PH�ONNEE N/ x(42 !� q . APPLICANT NAME(Print) 426. APPLICANT TITLE % 4v` J- L m bio s► N UPCF UST-A Rev.(12/2007)