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IFIED PROGRAM CONSOLIDATED FOW UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-FACILITY INFORMATION (One form per facility) TYPE OF ACTION ❑ 1.NEW PERMIT ❑ 5.CHANGE OF INFORMATION400 (Check one item only) ❑ 7.PERMANENT FACILITY CLOSURE ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILrrY CLOSURE ❑ 9.TRANSFER PERMIT I. FACILITY INFORMATION TOTAL NUMBER OF LISTS AT FACILITY " I FACILITY ID# _ t. (Agency Use Only) BUSINESS NAME(Same aFACILITY NAME.,DBA-Douq Bus.ms As) 3 BUSINESS SITE ADDRESS 103. CITY IN. FACILITY TYPE ❑ L MOTOR VEHICLE FUELING [3 2.FUEL DISTRIBUTION 41. Is the facility located on Indian Reservation or 405. C] 3.FARM ❑ 4.PROCESSOR C36.OTHER Trust lands? ❑Yes ❑No H. PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407. PHONE 408. MAILING ADDRESS 40. CITY 410. STATE 411. ZIP CODE 412. III. TANK OPERATOR INFORMATION TANK OPERATOR NAME 428-1. /PHONE 428.2 MAILING ADDRESS 428-3 CITY 4284 STATE 428-5 ZIP CODE 4284 IV. TANK OWNER,INFORMATION TANK OWNER NAME 414. PHONE 415, MAILING ADDRESS 416. CITY 417. 1 STATE 418. ZIP CODE 419. OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. ❑ 7.FEDERAL AGENCY ❑ 8.NON-GOVERNMENT V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY(TIt)HQ 44- 1 1 Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421. VI.PERMIT HOLDER INFORMATION Issue permit and send legal notifications and mailings to: ❑ 1.FACILITY OWNER ❑ 4.TANK OPERATOR 423 ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) 406. VII.APPLICANT SIGNATURE CERTIFICATION: I certify that the information provided herein is true accurate and in full compliance with legal requirements. APPLICANT SIGNATURE DATE 424 PHONE 4u APPLICANT NAME(print) 426, APPLICANTTITLE 427 UPCF UST-A Rev.(12/2007)