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i <br /> UNIFIED PROGRAM CONSOLIDATED FORM 1J(7 g r3 j� <br /> UNDERGROUNDSTORAGETANK ] <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One foam per facility) <br /> TYPE OF ACTION 1.NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400, <br /> (Check one ne n only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> vgp I. FACILITY INFORMATION <br /> AS-R- <br /> TOTAL NUMBER OF USTs AT FACILITY '°09FACILITY ID# _ 1. <br /> C'/ (�/� (Agency Use Only) 3 <br /> BUSINESS N E(samcaz FACILfrY NAME or DBA-Doing Bminas As) 3. <br /> /' mss v�.�cAE <br /> BUSINESS SITE ADDRESS 103. CITY 104. <br /> FACILITY TYPE ❑ 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 401 Is the facility located on Indian Reservation or 405. <br /> ❑ 3.FARM ❑ 4.PROCESSOR 5L6.OTHER S/f)f/DGC Trust lands? ❑Yes .KNo <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 409. <br /> Q,6zi 7a,472aS7 ce <br /> MAILING ADDRESS 409. <br /> .3 IV-26 S 72�7✓1,Ckl) <br /> CITY 419. STATE 411. ZIP CODE 412. <br /> r1'z _ GL S A 2 715 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAMEr ®0-usiz$/V�5�/ 418-1 PHONE 4za-2 <br /> '`ft'CSiJ ir-� �,viEiS 4s/- S4ads R <br /> MAILING ADDRESS 428.3 <br /> CITY 42544STATE 428-5 ZIP CODE 42M <br /> ®c 70 9s'z o <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> U/ / / S/ Ccs. ( ) <br /> MAH.ING ADDRESS 416. <br /> J 77t� <br /> CITY / /2/ /�� an. STAT e 418. ZIP C:D C/, � 419. <br /> OWNER TYPE: [14.LOCAL AGENCY/DISTRICT ❑ S.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 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 /> 406. <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) <br /> VII.APPLICANT SIGNATURE <br /> CERTIF I e information rovided herein is true,accurate,and in full compliance with legal requirements. <br /> AP DATE 30-42, 4+4 ( <br /> AP ICANT NAME(print) 426. APPL[ ATITLE 427 M <br /> UPCF UST-A Rev.(12/2007) <br /> I L{^ <br />