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53 <br /> UNIFIED PROGRAM CONSOLIDATED FORMUNDERGRO �( 2'7) <br /> STORAGETANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFO ION 2(� <br /> TYPE OF ACTION (One form per facility) <br /> 1.NEW PERMIT ❑ 5.CHANGE OF INFORMATION <br /> (Chock o4e ircm only) ❑ 7.PERMANENT FACILITY CLOSURE 400. <br /> ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> Ts AT FACR.ITY <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF US400. <br /> a (FACILITn'UYse ID#On(yJ ^ _ <br /> BUSINESS NAME(smneurAcnm wrote orDBA- `Ige^ N - 2 D <br /> Doing aminm Ap �+ <br /> BUSINES�S)'fe ADDRESS 7 , <br /> CITY <br /> FACILITY TYPE i I.MOTOR VEHICLE FUELING 4oi ( L C <br /> ❑ 2.FUEL DISTRIBUTION Is the facility located Indian Reservation or 405. <br /> 3 FARM 4.PROCESSOR 6.OTHER Trust lands? ❑Yp �No <br /> PROPERTY OWNER NAME <br /> II. PROPERTY OWNER INFORMATION <br /> _// 4a'!. PHONE 4N. <br /> MAILING ADDRESS _/1 ' 5� <br /> i <br /> 23 <br /> 'v 7 //V 409. <br /> CITY <br /> / C c- 410. STATE au. ZIP CODE 412 <br /> Com- 5' 5--3 76 <br /> III. <br /> TANK OPERATOR NAME TANK OPERATOR INFORMATION <br /> eoozy_ <br /> O <br /> �<Z 428.1. PHONE <br /> 428.2 <br /> MAILING DRESS (20-7) cZ , <br /> CITY 423.3 <br /> C aze� STATE gas ZIP CODE 428-6 <br /> TANK OWNER NAME Pi. TANK OWNER INFORMATION <br /> eolPHONE as. <br /> MAILING ADDRESS / o) 2 G 7 <br /> clTv <br /> _ � a /� � 416. <br /> A n C C 47). STATE A 418, ZIP COD aro. <br /> CC l)L <br /> 417. [S <br /> ./rL <br /> OWNER TYPE: ❑ 4.L AL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY <br /> El 6.STATE AGENCY 420. <br /> ❑ 7. DERAL AGENCY <br /> 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 urn questions. 421. <br /> VI.PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: ❑ 1,FACILITY OWNER IN <br /> 4.TANK OPERATOR 423 <br /> El 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) <br /> 406. <br /> VIL <br /> APPLICANT <br /> CERTIFICATION: [cer t t nformadon rovided her in Iihue accurate,and o full cons Bance with le al re uirements. <br /> APPLICANT SIGNATURE DATE ua. <br /> lit PHONE 4zs. <br /> APPLICANT NAME(pri ry 42ea APPLIC�TITLE /N <br /> 47) <br /> UPCF UST-A Rev.(12/2007) <br />