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JML <br /> 1r IED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION —FACILITY INFORMATION <br /> (One per Facility) �33 <br /> TYPI:iACTION ❑ I.NEA'PERMIT El 5. OF INFORMATION 7.PF:RMANF.NT FACIL1 CLOS U- nriU° <br /> (Check o,mxi/em mJS') ❑ ] RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.'I'RANSFER PERMIT tlVJ(CJ 7UI`�S <br /> I L <br /> I. FACILITY INFORMATION p <br /> TOTAL NUMBER OF US 1a'AT FACILITY u" FACILITY IDH _ _� q <br /> v Gf <br /> (Agency Use On/3) 3 j � e <br /> BUSINESS NAME IS4ma FACIMY NAnm ar osA-ortma eagms, T <br /> Axwlrn <br /> BUSINESS SITE AD SS 103. CFfY Ina <br /> FACILITY TYPE ❑ I MOTOR VEHICLE FUELING ❑ 2,FUEL DISTRIBUTION "a Lithe facility located on India Reservation or 405. <br /> ❑ 3.FARM ❑ 4.PROCFSSOR Z6 OTHER Trust lands? ❑Yes No <br /> 1 <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME yiPRONE uls <br /> MAILING ADDRE <br /> � �•a r r o S 7- S �e, �.Z� <br /> CITY 410. STATE 411 <br /> Q� ZIP CODE/ 4n <br /> l �? 1S0v4 � <br /> III. TANK OPERATOR INFORMATION <br /> TANKOPERATORNAME p 12x-1 PHONE 428.2 <br /> MAILING ADDRESS Ci'✓��— ( ) a2e.5 <br /> CITY 428"4ZIP CODE <br /> STATE 428•5 <br /> 4:n0 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME ^ 414. PHUNIL as <br /> MAILING ADDRESS 416 <br /> CITY 41? STATE 4M ZIP CODE 419 <br /> OWNER TYPES [1 4. LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY `� 6.STATE AGENCY 420 <br /> ❑ 7,FEDERAL ACiLNCY ❑ g,NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER I <br /> TY(TK)HQ 44- ( Call the State Board of EqualiM11011,Fuel]ax Division,if there are questions 421 <br /> V1. PERMIT HOLDER INFORMATION <br /> Issue Permit and send legal notifications and mailings to: I.FACILITY OWNERa2° <br /> ❑ 4.TANK OPERATOR <br /> ❑ 3.'TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DrVISION,SECTION,OR OFFICE(Required For Public Agencies nOnly) d <br /> L a V rat S c3 I i'f Z Y�I T ti pl 1's'aA t 1 H .1.ct G� ✓S+ °`iia G� f <br /> VIL APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that the information provided herein is true,accurate,and in full com liancervith la al requirements, <br /> APPLICANT. DAl'E 424 <br /> .�—) a PI10NF 425 <br /> r lc' <br /> APPLICANT NAME(print) 026. APPLICANTTTI LE 427 <br /> UPCF UST-A Rrv.(12/2007) \ <br /> IL 1 <br />