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-NP. 3 <br /> R-26-2012 09(04 AM j/CAO(Z il©G� �v 2 <br /> 6 <br /> UNIFIED PROCRAM CONSOLIDATED FORM faq0_1100 <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION—FACILITY EWORMATION(On,form par fhcillty) <br /> aan. <br /> TYPE OF ACTION El 1.NEW PERMIT C] S.CHANGE OF INFORMATION 7.PL•RMANENT FACILITY CLOSURE <br /> (Check one Itmn only) 9.TRANSFER PERMIT <br /> � I RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE <br /> I. FACILITY INFORMATION 6 <br /> 1, <br /> TOTALNUMBEROF USTSATFACILITY 4N. FACILITY TD <br /> ah (Agency Use Only) 3. <br /> Otis \ prylE(a PA ry NAME orO -D B Ar)` <br /> R ,..11LV IOJ. CI'T'Y 106. <br /> BUSTS& ITE A DR2 G <br /> FACILITY TYPE ❑ I.M TOR VEHICLE FUELING ❑ Z,FUEL DISTRIBUTION 1 sL facility <br /> lo Yes on Ind' NRoeaervation or <br /> 3.FARM 4.PROCESSOR 6.OTHER <br /> II, PROPtRTY OWNER INFORMATION <br /> S I °ar, PHONE 4oe <br /> PROPERT�S ERN S 10"1C � 54C�i--611 401) � <br /> l/�` <br /> 1 6 n. <br /> MAILIN 2p&pupgRE S ,t <br /> �7� ! f I{Y\ <br /> CITY <br /> +10. STATE „ Ott. ZIP CODE <br /> 4ia.1 � <br /> •(� Ill. TANK OPERATOR INFORMATION <br /> pQ 413-1. PHONE <br /> ,1 ,fie, 4atia <br /> rANxol tr�AIS <br /> MAILING_ADDRESS .7/ rl�41 r, ✓ ! . 1 <br /> �LIJ/y✓,t�� °xu 2tP q67-4!5- <br /> IV. <br /> 6 7 Ar 6w� <br /> aas.4 STATS �l {.�(�a <br /> ODE <br /> CITY <br /> IV. TANK OWNER INFORMATION <br /> M�f� ��{A�.1au. PHONE 416' <br /> TANKO FR ITV°I�YI.f' QY1�'�. O ''r V"F N• yb ) 40 <br /> 416, <br /> MAILING RE S I t <br /> (� <br /> CITY Eta zlPco ��� ^,a <br /> �/ L +1r� 1 STAT <br /> Iry n <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6,STATE AGENCY Q0. <br /> ❑ 7,FEDERAL AGENCY 9,NON.GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- Call tha State Board oFEquelizadon,Fuel Tax Division,If there are questions. <br /> Oat. <br /> VI.PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: ❑ 1.FACILITY <br /> TAMC O EA ER ❑ 4.TNK OPERATOR45 <br /> FACILITY OPERATOR <br /> d06. <br /> SUPERVISOR OF DMgiON,SECTION,OR OFFICE(Required For Pubic Ageneiea Only) <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION; I certify that the I fartnadon provided herela is true accurate end In 4t11 com IIBu a PHON Ire ulremeata. <br /> APPLICANT SIGNA . /,7 ➢ATE <br /> V� . <br /> APPLICANT NAME(pr' °aa APPL AN 'ItTLE Jj _/ .} °at <br /> t <br /> UPCF UST-A Rev.(11/3(107) <br />