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Rpr 16 10 11 : 24a _ _._ k P. 1 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK APR 16 2010 <br /> OPERATING PERMIT APPLICATION—FACILITY INFORMATION <br /> "fOnd':IbnnperfagiW , <br /> 'TYPE OF ACTION ❑�.,tLNEWPERMIT [IS.CHANGEOF INFORMATION ❑ 7.PERMANENT FACILITYCLOSURE. . <br /> (Cl crcone item ally) t{i'} RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 8.TRANSFL'R PERMIT - <br /> 1. FACILITY INFORMATION <br /> TOTAL NUMBER OFUSTs AT FACILITY 401' FACILDY <br /> (.tgerlcy Ilse Ortlyl "I <br /> BUSINESS NAME(s cxrnca.rry MME m ODA-thingiAa�Mans) �. Y <br /> A�TL�� .v lGl-:4 <br /> BUSINESS SITE ADDRESS `A los. CITY IN. <br /> FACILITYTYPE ro I.MOTORVEHICLEFUMNG ❑ 2.FUELDISTRIBUTION ms. Is the reeilily located on Indian Rcsmation or <br /> ❑ 2,FARM 0 4.PROCESSOR 0 6.01-HER Trust lends? ❑Yes ❑NO <br /> 11. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME *Co PHONE ^os <br /> MAILING ADDRESS 1�l!e ��� 40s <br /> CITY A10 STATE 4^ ZIP CODE <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 'Rs'i PHONE Ce <br /> r r � e,�q H (7=�� >: ,- <br /> MAILING ADDRESS Ctd <br /> CITY ^ STATE s=6'S ZIP CODE un6 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME ) 114. PHONE 415. <br /> MAILING ADDRESS 416. <br /> CITY 417. 1 STATE 41/. ZIPCODE aro. <br /> OWNERTYPC ❑ 4.RACAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY uo. <br /> ❑ 7.FEDERAL AGENCY E(g.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- Cali the State Board of Egmlimian.Furl Tac Division,if ince arequestions. 411. <br /> I. PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: I-FACB.ITYOWNER ❑ 4.TANK OPERATOR Cs <br /> ❑ 1.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> 06. <br /> SUPERVISOR OF OIV[SION,SECTION,OR OFFICE(Rcquiral For Public AgaxiesOMy) <br /> VII.APPLICANT SIGNATURE <br /> CERTIGICATION: I mrfify Wal the information ptwvIded herein is up.aaarate and in full caimplitusce with legal requirements. <br /> APPLICANT SIGNATURE DATE as PHONE J aa. <br /> C d 6 1. <br /> APPLICANT NAME(print) IJCANT TITLE <br /> UPCF UST-A Rev.(1212867) ^"'• r Tl .. . <br /> a <br />