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r <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUNDSTORAGETANK J <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION(one form per facility) <br /> 400. <br /> TYPE OF ACTION El 1.NEW PERMIT F-1 S CHANGE OF INFORMATION <br /> 7.PERMANENT FACILITY CLOSURE <br /> (Check one hem only) ❑ 3 RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> 1. <br /> TOTpy NUMBER OF USTs AT FACILITY 4N FACILITY ID# - - <br /> a�✓S n f� , (Agency Use On ) y. <br /> BUSINESS NAME(smnaF AMEwoaA-ncros ""¢A`) <br /> J! 7 <br /> 0Vn1T ffcl/»/tI� /CcaS 104.los. CITY <br /> BUSSS SITE ADDRESS STo�T-o^l <br /> / f . �J 2 S7 405. <br /> FACILITY TYPE ❑ 1.MC.TOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 4m TNae factlilansty❑Yes located on Indian Reservation or <br /> El 3.FARM ❑ 4 PROCESSOR 6.OTHER <br /> H. PR PERTY OWNER INFORMATION <br /> 407. PHONE 4N. <br /> PROPERTY OWNER NAME <br /> O / I 0U)tf ao4. <br /> Al, s <br /> Al410. STATE 411. ZIP CODE 412. <br /> CRY nn <br /> V7 <br /> III. TANK OPERATOR INFORMATION 428-2 <br /> 4211-1. PHONE <br /> TANK OPERATOR NAME <br /> 428-3 <br /> VTANKOWNER <br /> RESS <br /> 4za-a STATE <br /> 42&5 ZIP CODE 42&6 <br /> IV. TANK OWNER INFORMATION <br /> 414. PHONE 415. <br /> NAME (� <br /> ('01 <br /> � s- <br /> 41s. <br /> IYCyO <br /> MAII. ,,,�v 5 / Q /A( � 417. STATE 418. ZIP CODE _ 419. <br /> ITY <br /> C � l�,c�-LV"'' G� azo. <br /> OWNER TYPE: ❑ 4.LOCAL AGENCYIDISTRICI 5.COUNTY AGENCY [1 6.STATE AGENCY <br /> ❑ 7.FEDERAL AGENCY ❑ S.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER 4$1 <br /> TZ'(TK)HQ 44- Call the State Board of Equalvahoq Fuel Tax Division,If there are questions. <br /> VI.PERMIT HOLDER INFORMATION <br /> Z3 <br /> 1.FACILITY OWNER ❑ 4.TANK OPERATOR <br /> Issue permit and send legal notifications and mailings to: ❑ g TANK OWNER ❑ 5.FACILITY OPERATOR <br /> 406. <br /> VISOR OF D\MSIO ,SECTION,OR OFFICE(Required For Public Agencies Only) <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: Icer- that the information rovided herein is true accurate and is full com li 4nce PHONEaI re uirements. 425 <br /> APPLICANT SIGNATURE DATE <br /> - 2 ¢6821 <br /> an <br /> APPLICANT NAME(phut) 426. APPLICANT TITLE <br /> G xlor�e rte.. "D- ric_ r a� til <br /> 1^1 <br /> UPCF UST-A Rev.(12/200 <br />