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UNIFIED PROGRAM CONSOLIDATED FORM v, <br /> ���x� <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per fwility) <br /> TYPE OF ACTION ❑ 1.NEW PERMIT ❑'S.CHANGE OF INFORMATION [17.PERMANENT FACILITY CLOSURE 4m. <br /> (Check we imm only) ❑ 3.RENEWAL PERMIT <br /> El 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs ATF f7y 004' FACILITY ID k 1. <br /> -3 (Agency Use Only.) <br /> BUSINESS NAME(Svoc®FACB.IIYNA or DBA-Dj;Buu.A4) <br /> / rtxv5 <br /> BUSINESS SrjF ADDRESS toICITY / <br /> FACILITY TYPE 1.MOTOR VEHICLE FUELING403' . <br /> ❑ 2.FUEL DISTRIBUTION Is the Cwility located an Indian Reservation or 405 <br /> 3.FARM 4.PROCESSOR Ej 6.OTHER Trust lands? ❑Yes ❑No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 40. \ <br /> PHONE aos. <br /> MAILING ADDRESS �,t� / /� <br /> �O � 6 - . �/ 4os. <br /> CITY 4m. STATE 411. ZIPCODE Ota. <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR N^ 428-1. PHONE 428-2 <br /> MAILING ADDRESS <br /> l�25Y E_ l✓ lC/�j2 Oat, <br /> CITY 42a4 1 STATE ZIP CODE 42" <br /> !'S'-3 l <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME „ 414. PHONE 4 . <br /> Ve <br /> MAILING ADDRESS / � � i. , <br /> 416. <br /> CITY 417. STATE ve. ZIP COD�F., 419. <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.C UNTY AGENCY C16.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY S.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421. <br /> VI.PERMIT HOLD59 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 /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) 406 <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I certifv that the information provided herein is tra aceturate-and in f U com Lance with legal requirements. <br /> APPLICAbIrSIG3ATURE / DATE 424. PHONE 425. <br /> AP NAME(print) 4±6. ppP E 420 <br /> l <br /> UPCF UST-A Rev.(12/2007) <br />