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UNIFIED PROGRAM CONSOLIDATED FORM 1 <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION—FACILITY INFORMATION <br /> (One form per facility) <br /> IYPL OF AC HON ❑ I.NEW PLRMIT ❑ S.CHANGE OF INFORMATION ,� 7.PERMANENT FACILITY CLOSURE Ion <br /> (Check one item only) <br /> ❑ 3.RF.NIiWAI.PERMIT ❑ G.'TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> 'fC7TAL NUMBER 017 US-s AI-PACILI"I'Y aoa FACILFPYID# <br /> V GS (Agency Use OnllJ <br /> BUS INESS NAML(Sona.eACIUTY NAME.,oaA-u,nig aox,, i <br /> Nv�fJ sty VNAM <br /> n- .t�.�f '� 'I J�y� - <br /> SITEADQR.SS 10 CI'T'Y� . uJ,elm- r�.�TYPE ❑ I.MOTOR VEHICLE FUELING ❑ 2,FUEL DISTRIBUTION a0�. Is the facility Incited on India Reservaionor d05❑ 3.FARM ❑ 4 PROCESSOR 6 OI'HLR Trust lands? ❑Yes No <br /> II. PROPERTY OWNER INFORMATION <br /> OWNER NAME /, 4m PHONE 4nx <br /> ( c t �v� C�O Y'- GDURE{/moi/ 409 <br /> STATE 411 1LII CODE: nn6� l� III. TANK OPERATOR INFORMATION <br /> RATOR NAME <2x1 PHONE \ uxa <br /> MAILING ADDRESS ( l <br /> 428.1 <br /> CITY J2xA $'IAllt 42x1 ZIP CODIi .1296 <br /> IV. TANK OWNER INFORMATION <br /> 'TANK OWNLRNAMF 414 PHONE 1 415 <br /> MAILING ADDRESS <br /> 416 <br /> Civ 2 srnl'F 41x ZIP CODE 110 <br /> OWNER TYPE: [:14. 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(IR) HQ 44- Call the State Board al'Equal izauon,Fuel"fax Division,inhere are questions. 4x1 <br /> VI. PERMIT HOLDER INFORMATION <br /> IT <br /> Issue permit and send legal notifications and mailings lo: I.FACILY OWNER ❑ 4."TANK OPERATOR 423 <br /> ❑ 3.'fANKOWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) an6 <br /> UV / � �� GLlriZ i'Ironrvw �wQC �,✓eerwLf� �✓jfE �m✓ree v�t1 <br /> VII. APPLICANT SIGNA URE <br /> CE,11TIFICATION: I certif that the information provided herein is Inc,accurate and in full compliance with Ie al rr uirements. <br /> APPLICANT'. -�, DATE. 4:J PIIONF. 421 <br /> �c• ZL-3 . 2.4 �r� ( a.) s58'�LL <br /> APPLICANTNAME(print) a'6 APPLICANT TITLE: ❑2 <br /> J=NVtI <br /> t'P('F UST-A Rev,(12/2007) <br /> JUL 2 2 2014 <br /> 17NVIPnNMEf\:T°L H-^,LTH <br />