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2u.�J <br /> 0 l0 z <br /> UNIFIED PROGRAM CONSOLIDATED FORM lot( <br /> UNDERGROUNDSTORAGETANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATI N euxf / <br /> (One form Per 'ity) <br /> TYPE OF ACTION ❑ 1.NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE Ore <br /> (Check one item only) 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE [19.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 40°' FACILITY ID# t. <br /> '3 (Agency Use Only) <br /> BU (NESS NAMES uFACn.I'IY NAME or DBA-Doingllminor A4) 3. <br /> STH 110P g S o <br /> BUSINESS SITE ADDRESS to3. CTI'Y 104. <br /> lO (3 V o � , _ & R m a�>�recp <br /> FmLITY TYPE 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403' Is the facility located on IndianReservationReservation or 403' <br /> 3.FARM [14.PROCESSOR 6.OTHER Trust lands? [:]Yes PQ No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 402 <br /> ) <br /> MAILING ��- ky? 409. <br /> CITY 4ta� STATE 411. ZIP CODE412. <br /> ��-�r- <br /> HL TANK OPERATOR INFORMATION <br /> TANK OPERAT RNAME 4za-1. PHON 428-2 <br /> MAILING ADDRESS f6 S 5 4283 <br /> CITY 42844 1 STATE 428-5 ZIPCODE 42M <br /> C1111- <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME ) ru,y� 414. r 415. <br /> MAILING ADDRESS g tj S 416, <br /> CITY 417. STATE 418. ZIPCODE 419. <br /> c,�►���1; v� � 9 3 .7 2 I <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY(DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 4X <br /> ❑ 7.FEDERAL AGENCY Is S.NON-GOVERNMENT Ca R 9011 n1 0 N <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 are questions. 421. <br /> VI.PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: ® 1.FACILITY OWNER ❑ 4.TANK OPERATOR 423 <br /> ❑ 3.TANK OWNER ❑ S.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) 47- <br /> VH APPLICANT SIGNATURE <br /> CERTIFICATION: I certify t the infinirmadon provided herein is true accurate,and in full compliance with le al requirements. <br /> APPLICANT SIG DATE I � � 7 424 PHONE <br /> APPLICANTN (print) APPLICANT TITLE 422 <br /> �AMES ��0. (yeTa <br /> UPCF UST-A Rev.(12/2007) <br />