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UNO 1ED PROGRAM CONSOLIDATED FORM A C�I LB/10 <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facility) <br /> S.CHANGE OF INFORMATION [37.PERMANENT FACILITY CLOSURE <br /> 4w. <br /> TYPE OF ACITON Q}I.NEN AL PE L3FER PERMIT <br /> (Ch.cka.r nnn^^/Y) ❑ 3,RENtwwLPERMIT ❑ 6.TEMPORARY FACII.IrY CLOSURE [j9.TRANS <br /> I. FACILITY INFORMATION ) <br /> TOTAL N'M' R OF Dsra AT FACILITY .w. <br /> Use <br /> BUSE14ESS NAMP.(Cmne as FuciW(N{1ame or DBA-Do ag auuness As} <br /> 57<wCC 1 C Q_ lol <br /> ,r71y a <br /> BU STIE ADDRESS <br /> I.MOTOR VEHICLE FUELLNG ❑ 2.FUEL DISTRIBUTION �' b the facliry Iw'atod on Indian Reservation or <br /> FACILrTY TYPE ❑ Trvx lands? ❑ 1.Yes S 2.No <br /> 3.FARM [14.PROCESSOR 6.OTHER <br /> M PROPERTY OWNER INFORMATION us. <br /> �+ PHONE <br /> PROPERTY NAME \ rl It <br /> CC T 1 ax <br /> MABJjifi ADDRESS <br /> �_ - F)� p '�y� 411 <br /> �.-/ to. S 7E °t'- ZIP CODE <br /> CITY ��. <br /> UL TANK OPERATOR INFORMATION 4m <br /> vxn PHONE <br /> TAN OPERATORNAME�{] �' S�vZ 7) <br /> Lj ate\ 0.CV Om �^ <br /> ua-3. <br /> MAILING ADDRESS n <br /> F"hl.�. a s. ZIPCODE aawr <br /> CITY <br /> ltil ,..-tech <br /> IV. TANK OWNER INFORMATION 015. <br /> 4H. 1 PHONE <br /> TANK OWNER NAME <br /> 414 <br /> MAILING ADDRESS <br /> 4n. STATE <br /> Ota. 71PCODE 412 <br /> CITY <br /> Ogg Types ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY <br /> ❑ 6.STATE AGENCY 4Wa <br /> ❑ 7.FEDERAL AGENCY, ❑ S.NON-GOVERNMFNf <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER 4 <br /> Call the Stare E.omd of Egwllmtan.Fuel Tax Division,iftit mare questions. <br /> TY(TK)HQ 44 <br /> VL PERMIT HOLDER INFORMATION 4n. <br /> 1.FACILITY OWNER ❑ 4.TANK OPERATOR <br /> lsauc pcnnit and send legnl notifications and rnailhtgs to: ❑ 3.TANK OWNER J5jL 5.FACILITY OPERATOR <br /> 4os- <br /> SUPERYi50R OF DNISION,SECTION,OROFFlCE(RegvixdJor PvblicAgeneies Only) <br /> VII.APPLICANT SIGNATURE <br /> CERTI ICATION: I Im - t the information piw ided herein Is rine,accurate,and in full coos lienee wiONEaI rcu�irements- a,s <br /> APPLIC SISiDIA E ix _O T GD�e- <br /> I"'�'" att APPLICANT TLE \ <br /> APPL ANTNAME(linat) �W�L�- t.�•+ �r-- <br /> UPCF UST-A Rev.(12/2007)-12 <br /> wwsv.unidocsorg <br /> L 'd 90STSZB60Z 2SeJ'J eb4 :60 01 40 ReW <br />