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UNnUD PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK D/ <br /> OPERATING PERMIT APPLICATION—FACILITY INFORMATION <br /> (One fmm per facally) <br /> TYPE OF ACTION ❑ I.NEW PERMIT ❑ 5"CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 900 <br /> (Check we item only) fX 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> ' P6 rtM.. I41 �. S " Y..,M'a,,, Tk1 <br /> TOTAL NUMBER OF USTs AT FACMITY <br /> 4oa. FACII.TCYID#^ '••, t' - <br /> (Agency Use Only) �,� 3 got; <br /> BUSEVESSN (same esnncnn(Y�ruwm ok(n^sn��om�Bu»eev n,7 3. <br /> V_C <br /> BUSINESS-12 SITE ADDRESS � 1 % 1m. C9b&-- 0n ta. <br /> FACILITY TYPE 1?3 1.M&OR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION Is the facility located on Indian Reservation or 405. <br /> ❑ 3.FARM 4.PROCESSOR ❑ 6.OTHER Trmt lands? ❑Yes %Io <br /> PROPERTY OWNER NAME PHO14EE� _ as, - <br /> MAILINGADD S. 409 <br /> gsxa <br /> �rcacl eve <br /> CITY Oto. STATE 411 .ZIP CODE 412 <br /> TANK OPERATOR NAME .., 428-1. PHONE 4z 2 <br /> E"Pcn (� 53-7-0`ta3 <br /> pMAILING-�ADDRESS 428-3 <br /> CITY 42&4TS—TATE 42M ZIPCODE 4 a <br /> q&-%-7 <br /> o a„• INFO"RMA SON, M. <br /> TANK OWNER NAME 414. PHONE 415. <br /> r ( 1C <br /> MAILING ADDRESS 416. <br /> CITyaD �nG 47. ST�,T& 41e CODE 419 <br /> C..t T..' /1�1+AK 7 <br /> OWNER TYPR ❑ 4.LOCAL AGENCY/DISIRICr ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERALAGENCY S.NON-GOVERNMENT <br /> `L`'CO <br /> 1 <br /> ,.. a7— <br /> ff <br /> TY(TK)HQ 44- Q S Call the State Boes l ofEquelvatton,Fuel Tax Division,if dose are questions. 421. <br /> g ski <br /> i;4T;ry�'+4i z�'�»^��r ',�� �. �� ,���....p �,. :h � ..,,..,� , ;;-Y ��3. 1 Y�.r. �,3�"3•xeykr sal `N <br /> Issue permit and send legal notifications and mailings to: ❑ 1.FACILITY OWNER ❑ 4.TANK OPERATOR 421- <br /> I;Z3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) as <br /> a - VII t�PPI XCrAN1 SIGNATURE <br /> CERTIFI a inf mation provided herein is true accurst and in full compliance with legal requirements. <br /> IC �' DATE 42 PHONE ass. <br /> 5� ZOIO -0 <br /> APP N 425, PLICANT T1TLE 427 <br /> i <br /> UPCF UST-A Rev.(122007) �.:;1 <br />