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T� O52o�q$ EGEW <br /> UNIFIED PROGRAM CONSOLIDATED FORM MAR O 3 2O1 <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATI TAL <br /> ° PlT <br /> TYPE OF ACTION I.NEW PERMIT ❑ 5.CHANGE OF INFORMATION 7.PERMANENT FACILITY CLOSURE 4°0" <br /> (Check one item only) ❑ 3.RENEWAL PERMIT. ❑ 6.TEMPORARY FACILITY C�L,}O`S�URE �T❑ 9.TRANSFER PERMIT <br /> //TOTAL N[1[MRF�R n�P�USTs AT FA.CHAT(Y 7 K 4_04. FACILITY ID# M ' 1 -zj"A <br /> 9 0(7 ��® /�T (ABency Use Only) "i.. <br /> ' Sameaz FACnSr1 N4MP.nr DHA-D i gHusi As) .S'! �� ��'eR / L Qt9/� ✓/! / ��'9 <br /> BUSINESS SITE ADDRESS t . CITY 104. <br /> FACILITY TYPE ❑ 1.M0TOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION '/ 403" Is the facility located on Ir di eservation or 405. <br /> _❑- 4. OCESSO '6.OTHER /¢et)�/� 051Z Trust lands? [I Yes No <br /> II ROPER I Y 0W12 TNS ORl!?ATION,,;, <br /> PROPERTYOWNBRNAMF . , . ..408. <br /> NLULING ADDRESS <br /> 0L <br /> CITY 410. 1 STATE 111. ZIP cnnE 411 <br /> �F.AIoEETo2��'F` IRlVIA'I`iorr <br /> _..... . <br /> TANK OPERATORNAME _ 1-1' PHONE ' 428-2 i ' <br /> MAIL G ADDRESS -_ _"_....- - _ _ _ . _ _ _ _ .. 4294 <br /> - I <br /> CITY 4284 STATE 4285 ZIP CODE _ +zes� <br /> TANKOWNERNAME 414. PHONE - 415.1 <br /> MAILING ADDRESS <br /> CITY 417. STAT 418. ZIp COD �r 419. <br /> ® _ S <br /> OWNERTYPE: 4.LOCAL AGENCY/DISTRICT 472�5.COUNTY AGENCY Q 6.STATE AGENCY 4201 <br /> ❑ 7.FEDERAL AGENCY ❑ 8.NON-GOVERNMENT <br /> TY(TK)HQ 44- Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421.1 '- <br /> r p " I PI RMIT�0LD0Y2NTI01'T I <br /> Issue pennit and send legal notifications and mailings to: ❑ j FACILITY OWNER [14.TANK OPERATOR <br /> �.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> 4os.' <br /> SUPERVISOR OF DNISION,SECTION,OR OFFICE(Required For Public Agencies Only) <br /> r <br /> CE IFICATION: I certify that the information provided herein is true,aceurate and in full compliance with legal requirements. <br /> xAP I TSIC TTmp DATE 424• PHONE 425.; <br /> - .-.. - _ ___. =3c�9- <br /> CANINANIF _ _ _ - 4z°: APPLICANT TTTLF�. 427: <br />