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RECEIVE® <br /> UNIFIED PROGRAM CONSOLIDATED FORM DEC 02 2014 V <br /> UNDERGROUNDSTORAGETANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFO O <br /> TYPE OF ACTION Agrj.NEWPERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACIL 400 <br /> (Check one item only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION 0 0 3gg Pv\�S <br /> TOTAjcNUMBER OF USTs AT FACILITY 404 FACILITY ID# <br /> J OAJCI (AgencyUse Only) <br /> BUSINESS NAME(Same os FACILITY NAMBor DBA-Doing Busine.¢Aa) <br /> aD1 2C <br /> NCITY 5' <br /> BUSINESS SITE ADDRESS 04. <br /> 00 Sy ;12e1-,VCA <br /> RVA-) <br /> FACILITY TYPE 1-11.MOTOR VEHICLE FUELING [12.FUEL DISTRIBUTION 40J' Is the facility located on Indi Reservation or 4�' <br /> [13.FARM 4.PROCESSOR 6.OTHER Trust lands? ❑Yes No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 4e]. PHONE 408. 26 <br /> MAII Mr.ADDRESS 409. f0� <br /> t <br /> CITYOto. STATE 411. ZIP CODE 412. <br /> z i <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428.1. PHONE 428-2 <br /> i/'Vc. I (zo ) - 0 0 <br /> MAILING ADDRESS 428-3 <br /> c2- 0 alt A) II d <br /> CITY 4284 STATE 4ze-s ZIP CODE 428-6 <br /> L G9 ' <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 4F PHONE 415. <br /> E/Cf ,LAS ( Zo ) ->O O <br /> M L GADDRESS �� [+/t al° <br /> o / (/e ctoel t /Ca <br /> CITY 412 1 STATE418. ZIP CODE 419. <br /> �L <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY)DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY 8.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 HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: -K.FACILITY OWNER ❑ 4.TANK OPERATOR <br /> azs <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> 406. <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) <br /> VIL APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that the information provided herein is true,accurate,and in full compliance with legal requirements. <br /> APPLICANT SI ATUDATEy 2 I 424. Reg / <br /> 3j 70'q9 <br /> PPLICANT NAME 'n 426 1 APPLICANTTITLE 427 <br /> 6 t-� "t 4 l2 C_i C,4 1'vt Lo t2 <br /> UPCF UST-A Rev.(12/2007) <br />