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DE <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK (/E� (I N1ENT HEAL H ���\\ <br /> OPERATING PERMIT APPLICATION- FACILITY INFORM „ /SE4V!CES <br /> (One form per facility) <br /> TYPE OF ACTION ❑ L NEW PERMIT 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 40a <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 4N. 1 FACILITY ID# _ C7 C _ L� Z �`j 1. <br /> 42 (Agency Use Only) JFJ 11l <br /> BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3. <br /> ci "", <br /> BUSINESS SITE ADDRESS 103, CITY 1a. <br /> R , �M <br /> FACILITY TYPE ❑ I.MOTOR VEHICLE FUELING 2.FUEL DISTRIBUTION 403. Is the facility located on Indian Reservation or 405. <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑ I.Yes X 2.No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE z/08,��/ 408. <br /> c - f.+a- <br /> MAILMDDRE <br /> GASSI) f 4W <br /> 2S -7 A/ V <br /> CITY 410. STATE 411. ZIP CODE 412 <br /> �. C--14 9s3✓a <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1 PHONE 428-2. <br /> ivr4 c ) <br /> MAILING ADDRESS 428-3, <br /> CITY 4284. 1 STATE 4285. ZIP CODE 428x. <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME II (r' 414_ PHONE 2 p 415. <br /> C17aT e � 2oT ) S9� - <br /> MAILING ADDRESS 1 416' <br /> 25 ( <br /> AW . /I <br /> CITY 417, STATE 418, ZIP CODE 419. <br /> K CA f53(. � <br /> OWNER TYPE: If&4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY ❑ 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 1 1 1 /qj A I I I Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421. <br /> VI.PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: 1.FACILITY OWNER ❑ 4.TANK OPERATOR 423_ <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Requiredfor Public Agencies Only) 406. <br /> VH.APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that the information provided herein is true accurate and in full compliance with legal requirements. <br /> APPLICANT SIGNATOR > DATE 424. 1 PHONE 4u. <br /> 5-- /5r- , 9 2,o9 S99-Z/5 <br /> APPLICANT NAM (print)' 426 APPLICANT TITLE // 427 <br /> ON eP4' 00viSL,L Glon..lc.s �7r�c fO.t. <br /> UPCF UST-A Rev.(1212007)-112 w .unidocs.org <br />