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.unuo,anvur.rvrii:rvr-��a::x�rTars�s _ _ _ _ � .�+" ris <br /> UNIFIED PROGRAM COI:ye1I:W [TED i1 i0 <br /> W:Vf3Y:ItC1tULPT�3T'L.�.+�l;lE'��1�i'�: <br /> GPLLS." I:Tc: k'L3:1L'L'rE.�Pi.IC:1TIO:ti--fAe',1 .1:Y 1?:F:iIt".vl.<�.'L=O�?1 <br /> (Oce form prr facility) <br /> TYPE OF ACTIONI.NbW PERMIT' ❑ J.CHANGE OF INFORMA:S`.n [_' :' PL^.lM/1 :'•if F"CTS IT, I;;1n5-FIT 1pD' <br /> (Check m Km enlr) ' ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> ,. _, ..,. ..... ter•.-•i.... .-..-., ..._._� ___.... ._.__....,.-... <br /> Y: FACIIrIif'�YF��FOIfMAI�'%014 <br /> TOTAL NUMBER OF USTS AT FACfLITY 4i'i FA(E.TTY W a _ <br /> mle, 7r Uxe Ony) I <br /> BUSUNFaS NAME lar,.r'6'�cluiv AiAlntwnnn,-naoyawrwxl i <br /> BUSINES ITE ADDRESS 10;. CI7Y 104. <br /> 1? <br /> FACId1Y TYPE JYI.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION Is the facility located on Indian Rso ation or <br /> 3.FARM 0 4.PROCESSOR [16.OTHER Trust lends? ❑Yes ©-Ko <br /> I[: PROPETtI1 OWLVT~RIIVCORMATIOI>T <br /> PROPERTY OWNER NAME PHONE <br /> MAILING ADDRESS <br /> .r <br /> C I6. STATE "II- ZIPCODE 412. <br /> 411P P"- <br /> ID TAN�C;OPE�AxOIt1NFORMATIgN" <br /> TANK OPERATOR NAME 4 1. PHONE 47 <br /> f ` <br /> MAILING ADDRESS _ — -- — _ -———--— 42W <br /> CITY —f r eTATF— 429-5 ZIP CODE <br /> IV: TAN::OW :�ltLVF�.RIt ION <br /> TANK OWNER NAME <br /> +14. 1 HC AE -415. <br /> ! � <br /> G ADDRESS 416. <br /> CITY / ,7 41¢ STAT 412. ZIPCODE 414. <br /> OWNEi.TYPn: �^, '.,,C^.fu.i+vENCiiiui3 i KIL;r 11 5-COTTN'rY"rte"+CY ij o.sl AiE AGENCY 426. <br /> ❑ 7..TT`VITAL AGENCY ❑ S.NON-0OVERNMENT <br /> B J site of T Q[JAt�zaTlorrllSx s l4�RA k E;AC I�{SN�11FtIMBEIa<- <br /> 1Y(TIgHQ" ,^ Call dle State Board of Equalization,Fuel Tax Division,if there tae questiotn. 421. <br /> i'L PERMIT i�OLD rWO'R KATION <br /> Iasis permit end aend Iegd notiftcatiow and--fl :a: U 4,TANK OPERATOR 423 <br /> ❑ 3.TANK OWNER ❑ S.FACILITY OPERATOR <br /> SUPE)3:iJIA OF JlVioION,SECTION,OR OFFICE(Required For Public Agencies Only) 406. <br /> VII,APPLICANT SIGNATURE <br /> CERT YICAT:.N: .'n rdf+chat We laformadoo provided herds It accurate and in fall coax nae all6 requirements. <br /> APPLP'A:4T SP SP iN.TUN DATE , PNONE <br /> ,APPIAC" 7NAME) 416. APPLICANT TITLE 427 <br /> UPCr USI-A M.(12/2007) <br />