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APR-26-2012 0904 AM �1 2 P. 3 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK 1 <br /> OPERATING PERMIT APPLICATION—FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION 0 L NEW PERMIT [' 5.CHANGE OF INFORMATION 7.PERMANENT FACILITY CLOSURE <br /> (Check one Irma aaly) ElI RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION/ 3 6 <br /> TOTAL NUMEER OF USTs AT FACILITY 604 FACILITY ID <br /> BUS $y (Ag my UN Only) z a <br /> S e�tE(s.mqu va try nnME orPyq-o ar� t <br /> OGL 1 'e 6lL .d1. <br /> BUSIf(ES�S- TEA D� i CITY icw, <br /> LI 7 G <br /> FACILITY TYPE ❑ L M TOR VEHICLE FUELING ❑ 2,FUEL DISTRIBUTION JU, Ia tha facitily located on I'd Reernation or 405. <br /> 3.FARM 4.PROCESSOR 6.OTHER 'host lands? 0 Yes No <br /> II, PROPERTY OWNER INFORMATION <br /> PROP Ck O ERNM4 S , I t d ���0j ate. PHONE 4N. <br /> MAILING DRE S °� <br /> D f rl wt <br /> CITY <Ic. STATE - °u. ZIP CODE '^� au. <br /> III. TANK OPERATOR INFORMATION 5�(/ <br /> TANK✓Y�I IRINAME� +ae-tP(HWONE ) vL 24211-2Ur�� � <br /> MAILINGADDRESS <br /> °a,� <br /> CITY � M °as° STATE °ate� ZIP CODE use g52Ds <br /> IV. TANK OWNER INFORMATION <br /> TANK cL^l IG�Y2 �!►1� 4� 1� u. (Hlb ) �`Z' 2 � °,5416.. <br /> Mnamc� Ross / <br /> CITY U °n. $TA Gia, ZIP CO J Erg. <br /> O <br /> OWNER TYPE: ❑ a,LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY <br /> ❑ 6'STATE AGENCY azo. <br /> [37,FEDERAL AGENCY 8,NON-GOVERNMENT <br /> V, BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 1Call the State Board of Equalization,Fuel Tax Division,if there are quastions. °tl. <br /> VI.PERMIT BOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: ❑ ],FACILITY OWNER ❑ 4.TANK OPERATOR 4n <br /> TANK OWNER ❑ 5,FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Pub is Agencies Only) ws. <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: 1 cert that the I formation Pro4ded herel0 is true accurate and In full compliance with legal requirements. <br /> APPLICANT SIGNA �j g/ q <br /> ° 0 DATE I h au. PH' <br /> APPLICANT NAME(pr' V� +ab. APPL AN 'C1TLEn2> <br /> V11��P ,f <br /> UPCF UST•A Rev,(12/207) <br />