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z37z (0a Aw .w&IED PROGRAM CONSOLIDATED FOAM^ UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-FACILITY INFORMATION «� (One form per facility) TYPE OF ACTION L NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400 (Check one item only) 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT I. FACILITY INFORMATION TOTAL NUMBFR OF I iSTc FACILITY 404' FACILITY ID# (Agency Use Only) AUS SN E(Sa aFACR1TYN PAEar DBA-noagl3uamess As7 3 BUS ES IV DRESS 103. CITY laa. FACILITY TYPE (i1.MOT R VEHICLE LING ❑ 2.FUEL DISTRIBUTION 403" Is the facility located on In�Reservation or 40s_ ❑ 3.FARM C] 4.PROCESSOR 6.OTHER Trust lands? ❑Yes J�No U. PROPERTY OWNER INFORMATION PROPERTY OWNER NAME A � 407 P �N� MAIL��ADDRUSS CITY 410. 1 STATE 411 ZIP C¢§E� m2. IH. TANK OPERATOR INFORMATION ��[[// TANK OPERAT RNAME 428-1, /PHONE 428-2 MAILING ADDRESS 428.3 CITY 4284 STATE 428.5 ZIP CODE 428A IV. TANK OWNER INFORMATION TANK OWNER NAME 414. PHONE 415. MAILING ADDRESS 416. CITY 417. 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(TK)HQ 44- 1 1 Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421 VL 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) uob_ VII.APPLICANT SIGNATURE CERTIFICATION: I certify that the information provided herein is ue,accurate,and in full co m Bance with legal requirements. APPLICANT SIGNATURE DATE 424 1 PHONE 425. APPLICANT NAME(print) 426. APPLICANTTITLE 427 UPCF UST-A Rev.(12/2007)