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UNIFIED PROGRAM CONSOLIDATED FORM V (lam <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION(Oneform per facility) <br /> TYPE OF ACTION ❑ 1.NEW PERMIT 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400. <br /> (Check one item only) ❑ 3 RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 40a. FACII.ITY ID# <br /> 3. <br /> BUSINESS NAME(some 1 (Agency Use Only) <br /> ancnrrr ZorGBA-DoiegBesineo As) <br /> 01 (LD ovC-'-S L) 0. cITY 04 <br /> BUSINESS SITEADDRESS C19�-D <br /> AJ O R 405. <br /> FACILITY TYPE C] 1.MOTOR VEHICLE FUELING �2.FUEL DISTRIBUTIONam.ON Is the facilitylocated on Indi Reseryation or <br /> El3.FARM [14.PROCESSOR ❑ 6.OTHER Trust lands? []Yes No <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME am. PHONE <br /> `I ) 408. <br /> D2AU S 201 L <br /> 409, <br /> MAILING ADDRESS <br /> DP- 411. a¢. <br /> CITY 410. STATE ZIP CODE <br /> hoc o CA gS7-o3 <br /> HL TANK OPERATOR INFORMATION <br /> TOPTOR NAME 423-1. PHONE 428-2 <br /> ANK ERA <br /> 428-3 <br /> MAILING ADDRESS <br /> 42" STATE <br /> 428-5 ZIP CODE 4211-6 <br /> CITY <br /> IV. TANK OWNER INFORMATION <br /> TANKOWNERNANM �1(` 414. PHONE 415. <br /> ,� 14'S' V E > 416. <br /> MAR.ING ADDRESS <br /> CITY 417. 1 STATE 418. 1 ZIP CODE 419. <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY <br /> azo. <br /> ❑ 7.FEDERAL AGENCY ❑ s.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> azl. <br /> TY(TK)HQ 44- Call the State Board of Equalization,Fuel Tax Division,if there are questions. <br /> VI.PERMIT HOLDER INFORMATION <br /> azs <br /> Issue permit and send legal notifications and mailings to: 1.FACILITY OWNER ❑ 4.TANK OPERATOR <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> 406. <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I cern that the information rovided herein is true Aaccurate,and in full co m liance wTE �itth legal requirements. 423 <br /> APPLICANT SIGNA D ®A O E <br /> 426. APPLIC T T TLE 7 427 <br /> APPLICANT NAME(Pri ) <br /> UPCF UST-A Rev.(1212007) <br />