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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUNDSTORAGETANK OPERATING PERMIT APPLICATION-FACILITY INFORMATION(Oneform per facility) 400. TYPE OF ACTION ❑ 1.NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE (Check one item only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT I. FACILITY INFORMATION 404. TOTAL NUMBER OF USTs AT FACILffY FACILITY ID# _ - (Agency Use Only) 3. BUSINESS NAME(sun.s FACILITY NAME mDBA-Doing Bmineu As) 103. CITY 104. BUSINESS SITE ADDRESS 403. 405. FACILITY TYPE ❑ 1.MOTOR VEHICLE FUELING [12.FUEL DISTRIBUTION Is the facility located on Indian Reservation or Trust lands? [I Yes ❑No 3.FARM El 4.PROCESSOR ❑ 6.OTHER II. PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407. PHONE °m' 409. MAILING ADDRESS 410. CITY STATE 411. ZIP CODE 41 , III. TANK OPERATOR INFORMATION 42x-1. PHONE 428-2 TANK OPERATOR NAME 4±8-3 MAILING ADDRESS CITY 4284 1 STATE 4'-8'5 ZIP CODE 428� IV. TANK OWNER INFORMATION 414. PHONE 415. TANK OWNER NAME l 416. MAILING ADDRESS CITY an. 1 STATE 418. 1 /IF CODE 419. OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. ❑ 7.FEDERAL AGENCY ❑ 8.NON-GOVERNMENT V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER 421. TY(TK)HQ 44- Call the State Board of Equalization,Fuel Tax Division,if there are questions. VI.PERMIT HOLDER INFORMATION 433 Issue permit and send legal notifications and mailings to: ❑ 1.FACILITY OWNER 4.TANK OPERATOR ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR aa. SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) VII.APPLICANT SIGNATURE CERTIFICATION: I certft that the information provided herein is tr DATE urate,and in full com liance with legal requirements. 4zs APPLICANT SIGNATURE 4'-4. PHONE APPLICANT NAME(print) 4±6. APPLICANT TITLE a29 UPCF UST-A Rev.(1212007)