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P. 12 <br /> MAY-31-2010 11 :26 AM R=- <br /> LIT ED PROGRAM CONSOLIDATED FORM <br /> /UNDERGROUND STORAGE TANK � <br /> OPERATING PERMIT APPLICATION —FACILITY INF6RMATION(one form Per facility)) <br /> 40a, <br /> 7.PERMANENT FACILITY CLOSURE <br /> TYpE ON ACTION I.NEW PE:RMII ❑ 5.CHANGE OF INFORMATION 9,TRANSFER PERMIT <br /> (LMieck ono nnn onlrl �7 RENEWAL.PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE Q <br /> I. FACH,ITY INFORMATION <br /> TOTAL NUMBER OP US N AT PACILI'IY 411, (Agermy Um Only) 5_ <br /> ♦.) 4 <br /> BUSINESS NAMG($..I FACILITY NAME m119A-tb'mY <br /> wcod m 3. CITY o4. <br /> BUSINESS SITE A DRESS as. <br /> Q��'4Cr M'' Is lha t'acilily located on 1 ian Resarv9tlon or <br /> '�I.MOTOR VF.HICI.E FUEL ANG ❑ 2.FUEL DISTRIBUTION <br /> �jIFACILI'IN TYPE mast lands? Yes <br /> 3.FARM n PROCFSSOR 6.OTHER <br /> B. PROPERTY OWNER INFORMATION 4e9 <br /> c usE 4n PHONE <br /> PROPERTY OWNERNAMF. SIS $ �f -m 33y -� .3s <br /> ac9. <br /> MAILING ADDRESS / Q. <br /> CITY <br /> PiL <br /> (e�. l.0 J . .� ' (e ae� lin SIATj, all. ZIP CODE <br /> �o�/ Ela. <br /> III. TANK OPERATOR INFORMATION HONE 42S-2 <br /> TANK OPERATOR NAME!, (.76 <br /> . 1 3-3 f' <br /> res 00 d.4140 11111. 42&1 <br /> MAILING ADDRESS ,�,y,� <br /> -A. 44 - a2s 5 ZIP CODE. 4196 <br /> 4264 STATE p. <br /> CITY <br /> IV. TANK OWNER INFORMATION 415 <br /> 414. PHONE <br /> TANK OWNER NAMEINO <br /> I M�ILO l �(o DRF.S tA�2-l. HF17 l -O' <br /> 417 STA41 e. 21P COCOS u9. <br /> CITY TE %Se <br /> 5 t OLINTY AGENCY D 6.STATE AGENCY 4M <br /> OWNER <br /> TYPF.�. C34.LOCM.AGENCY/DISTRICT ❑^``� <br /> 7.FF.DERALAGE:NCY EPI.NON•GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER 431 <br /> TY (TK) HQ 44- l7 .� 6 Call the State Board or Equalization,Ftal Tax Division,if them are questions. <br /> VI. PERMIT BOLDER INFORMATION 4 <br /> L FACILITYOWNER 11 4.TANK OPERATOR <br /> {ssue permit and xnd Icgal notitieatiens and mailings ur, ❑ 7 TANK OWNER ❑ 5.FACILITY OPERATOR <br /> ba. <br /> SUPERVISOR OF DIVISION,SUCTION.OR OFFICE(Required For Nihlie Apneiee Only) <br /> VII.APPLICANT SIGNATURE <br /> 414. PHONE 425. <br /> CFRTIPICA'I'ION: I cert) that the Information provided herein is true,accurate and in full eom lienee W, It k el requirements. <br /> APPLICANT 5{GNAT11 _ — )0 O <br /> ear <br /> 476. APPLICANT'CITLE <br /> APPUCnN-i'NAME(pn j A � <br /> UPCF UST•A Rev.(13/2M7) IF y M <br /> _ <br /> 3 <br />