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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUNDSTORAGETANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION ❑ 1.NEW PERMIT 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 40), <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 4M. FACILITY LD# _ _ t. <br /> r� (Agency Use Only) I I I I I y <br /> BUSINESSN(A�M E(Sam as Facility Name DBA Doing usiness AsJ FA oz>o-3 b-7a�� L` oZ. 353 <br /> Lt �r,X 211^- s oc.i �_�c� <br /> BUSINESS SITE ADDRESS <br /> J w voIm' CITY <br /> - b fn 109' <br /> FACILrrY TYPE )RC1.NMTORVEHItLE FUELING [12.FUEL DISTRIBUTION 403 Is the facility located on Indian Reservation or 40' <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑ I.Yes T�L2.No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNAME 401, PHONE 4011. <br /> NE <br /> ;200 e"-1 <br /> MAILING ADDRESS <br /> 17-/ -7 N, <br /> CITY 410. STATE 411. ZIP CODE 412. <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPER/e�/TORN o 429-1. PHONE p _4zs-2. <br /> �t ^tt=o�� S C�L t rrJ` ✓ L✓S -Lv� C 'T D I- d S <br /> MAILING ADDRESS <br /> CITY <br /> 44". STATE 4211-5. 1 ZIP CODE 4286. <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHG[{EU <br /> MAILING ADDRESS / / 416' <br /> .Vl i <br /> CITY 417. 1 STATE, Ota. ZIPCODE�J/dam 419. <br /> L C/ <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 42A <br /> ❑ 7.FEDERAL AGENCY 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY('pg)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: ❑ i.FACILITY OWNER 15�4.TANK OPERATOR <br /> 4z. <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required fir Riblic Agencies Only) °� <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I ceXtIfy tbpt theAnformadop provided herein is true accurate and in full compliance with legal requirements. <br /> APPLICA�� ' 425.424 <br /> 00 <br /> APPLICApnNryT NAME(pmt)/ f 4'-6 APP ANTTITLE 422 <br /> )M/G - S . yam:,i-Ge ✓?J re's r <br /> UPCF UST-A Rev.(12/2007)-1/2 w .unidocs.org <br />