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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTIONI.NEW PERMIT El5.CHANGE OF INFORMATION E] 7.PERMANENT FACILITY CLOSURE 400. <br /> (Check vvc nrn avly) ❑ 3 RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TQT4L NUMBER OF USTs AT FACMTY 404' FACILITY ID# <br /> l /i/iTf� 6U R7�f•✓ (Agency Use Only) <br /> BUSINESS NAME(s .FACum Nneo:vrueA-Dans Bln m) 3 <br /> BUSINESS SITE ADDRESS 103 CSS!(�� T��✓ N <br /> FACILITY TYPEl.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 4m_ Is the facility located on Indiag.Reservtion or i05- <br /> 3.FARM 4.PROCESSOR 6.OTHER Trust lands? ❑Yes No <br /> IL PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 42. PHONE 4m. <br /> D -1v�0 <br /> MAILING ADDRESS 409 <br /> e2 1Zs9t0; e/ Lam« <br /> TY 41.. STATE 411. 1 ZIP CODE 4¢ <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 429-1- PHONE 429-2 <br /> MAILING ADDRESS 429-3 <br /> n <br /> ,e/7 <br /> CRY 42. STATE 429-3 1 ZIP CODE ,zea <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME _� 414. PHONE 413 <br /> -VA-TEM ADDRESS <br /> F . <br /> cz o�-c d <br /> CITY O� .� r 41z STA*F� ,ts. z�coji 1- 419. <br /> /O Calf 7 y( 'c/ <br /> OWNER TYPE: 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 42°. <br /> L3 7.FEDERAL AGENCY .NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 1 1 Call the Slate Board of Equalization,Fuel Tax Division,if there are questions. 423 <br /> VI.PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: ❑ FACILITY OWNER ❑ 4.TANK OPERATOR 4n <br /> rk TANK OWNER ❑ 5.FAciLrrY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) 4o <br /> VII.APPLICANT SIGNATURE <br /> CERT FICATION: I certify that the information provided herein is true,accurate arid in fup compliance with legal requirements. <br /> APP CAM SIGNE DATE / 424 1 PHpN Q ,ssAPP . <br /> LI NAM 626- APPLIC cl' <br /> UPCF UST-A Rev.(12/2007) <br />