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low <br /> UNIFIED PROGRAM CONSOLIDATED FOMvi <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form Per facility) <br /> TYPE OF ACTION ❑ 1.NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400. <br /> (Check O°e son Wty) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE <br /> ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404. FACILITY ID p1. <br /> (Agency Use Only) F - O ( - l 7 6j <br /> BUSINESS NAME(sass.FAcamNAt�/m Da/n-D�[w.6rm A.) 3. <br /> j D SQC v"Lc- T�cT is J it Yt L_ , <br /> BUSINESS SITE ADDRESS 103. CITY 1a. <br /> qvIt Gvafwjl G.ra r ^1171, >l <br /> FACILITY TYPE 011.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION ao3' Is the facility located on Indian Reservation or <br /> 3.FARM 4.PROCESSOR 6.OTHER Trust lands? ❑Yes ❑No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME , / am. PHONE 4m. <br /> A'apt jl, f-10 `tLl9 - br>;99 <br /> MAILING ADDRESS r�d9 - -I9 409. <br /> �1? •U. �1. / C� <br /> C /7l Omits dI'1 410. STATE arse <br /> all. "1)i b O� <br /> M. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME aze-1. pHONE 428-2 <br /> MAILING ADDRESS 428-3 <br /> CITY '/ 9oln i4i4xlrl4�" Crcu.�4284 9.sf <br /> 1 STATE 426-6 ZIP CODE 4m5 <br /> ,1��prl..rrry' T1Mr77�n C l9 9 ci 6 Fr6 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 413. <br /> MA(I�L[I3NG ADDR/Ess ®® 415, <br /> C1TYr417. ST1A419 <br /> aeW1(,1,/ '4 . q Oh3 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 4za <br /> ❑ 7.FEDERAL AGENCY 93,13.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: ❑ 1.FACILITY OWNER ❑ 4.TANK OPERATOR 4n <br /> V43.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I that the information provided herein is true,accurate,and In full compliance with legal requirements. <br /> APPLICANT SIGN DATE 424. 1 PHONE <br /> 3/ 7,- iU r/v 396- 36..M <br /> APPLICANT (prigt) aw. APP 7T E <br /> m�n � V� o � <br /> e� <br /> UPCF UST-A Rev.(12/2007) .aka �az sin r+�fl�+s� <br />