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� 34� ( q <br /> UNIFIED PROGRAM CONSOLIDATED FORM 43Iv <br /> A <br /> UNDERGROUND STORAGE TANK JJZ�B <br /> OPERATING PERMIT APPLICATION-FACILITY INFORi'LATIO per facility) -O <br /> TYPE OF ACTION ❑ I.NEW PERMIT ❑ 5.CHANGE OF INFORMATION �y 7.PERMANENT FACILITY CLOSURE 400 <br /> (Check one day only) ❑ 3.RENEWAL PERMIT EJ 6.TEMPORARY FACILITY CLOSURE / ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION I+[ <br /> __7('11191c, <br /> 7 0 11 <br /> TOTAL NUMBER OF USI +oa_ U <br /> _ n FACILITY IDR _ _ 13 <br /> c�✓Sr t�f=� (Agency Use Only) b <br /> BUSINESS NAME(Swe u FACILITY NAME or DBA-Doingli roar AM) 3. <br /> 5 JtnJ �r0(Jn[T v/YI/}/F /C CaS <br /> BUS ESS SITE AD SS 103. CH7 IN. <br /> / S <br /> Z . S7o-a-rw <br /> FACILITY TYPE ❑ I.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 003' Is the facility located on Indian Reservation or 40.1' <br /> ❑ 3.FARM ❑ 4.PROCESSOR W6.OTHER Trust lands? ❑Yes o <br /> II. PR PERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 408. <br /> Z_� )04VOIM <br /> MAI/,�IN�AD/RESS 400. <br /> CITY 410. STATE nu. ZIP CODE 412. <br /> tom G9 9S'o�®a <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-I. PHONE 429-2 <br /> ( ) <br /> MAILING ADDRESS 428-3 <br /> CITY 428-0 STATE 4'-8-6 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415. <br /> MAILLII)I�Cy RES 416. <br /> C1 ��a--t,,7rr. STATE_ - nle. ZIP CODE �� 41e. <br /> T��� <br /> OWNER TYPE: [:14.LOCAL AGENCY/DISTRICT �g 5.COUNTY AGENCY El 6.STATE AGENCY 420. <br /> El 7.FEDERAL AGENCY /❑ 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TZ'(TK)UIQ 44- Call the Slate 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: �I.FACILITY OWNER El 4.TANK OPERATOR 423 <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> VISOR OF\ION,SECTION,OR OFFICE(Required For Public Agencies Only) 906 <br /> i { 1✓aIR ioRR <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that the information provided herein is trne accurate and in full compliance with legal requirements. <br /> APPLICANT SIGNATURE DATE 424. PHONE 425 <br /> O 2 ¢681 <br /> APPLICANT NAME(prino 426. APPLICANT TITLE <n <br /> �iabrie ar I>'Ir« r a4 M <br /> UPCF UST-A Rev.(12/2007) <br />